BSc Hons. Nursing Dip HE Nursing Graduate Diploma

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1 FACULTY OF HEALTH BSc Hons. Nursing Dip HE Nursing Graduate Diploma Module GM4078: Core Nursing Skills & Their Theoretical Frameworks MODULE GUIDE AND WORKBOOK APRIL 2006

2 Page Contents 1 Module Co-ordinators and contacts 2-4 Module Guide 5-6 Reading List 7 Accessing the Physiology & Skills Websites 8 Section One 8 Session 1 Introduction to the Workbook 9-20 Session 2 Moving and Handling Session 3 Infection Control + self-directed activity Session 4 Psychological aspects of Stress and Coping + self-directed activity Session 5 Personal Safety 39 Section Two Session 6 Communication Session 7a The Physiology of Respiration self-directed activity Session 7 Respiratory Rate and Sputum 63 Session 8 Communication and Culture Session 9 Respiratory Function Session 10 Cells, Genetics and Cancer 77 Section Three Session 11 Circulatory Physiology Session 12 Heart Rate and Blood Pressure 90 Section Four Session 13 Digestive System Session 14 Nutrition and Feeding Session 14a Pressure Ulcers self-directed activity Session 15 Renal System Session 16 Dehydration and Fluid Balance Session 17 Psychological Impact on Health 118 Section Five Session 18 Temperature Regulation Link Session Session 19 Urinalysis 133 Section Six Session 20 Drug Administration + self-directed activity Session 21 Depression Link Session Session 22 Health Assessment Link Session + self-directed activity 151 Session 23 Exam Preparation 151 Other Associated Skills Appendix One: CPR Appendix Two: Handout for Injections Appendix Three: Oral Care 165 Appendix Four: Sample fluid balance chart 166 Appendix Five: Sample Observation chart Appendix Six: Blood Pressure Measurement Technique Appendix Seven: Revision Questions 181 Appendix Eight: Sample MCQ Answer Sheet 182 Postscript Contributors

3 Module Co-ordinators & Contacts: Skills Team Physiology Team Dip HE: Stefan Cash & Helen Clarke 221, Heathfield 202, Heathfield / Bridget Malkin & Melanie Shale 213, Heathfield 207, Heathfield BSc: Andrea Shinnick & Melanie Shale 208, Heathfield 207, Heathfield Grad Dip: Kirsty Wedgbury & Ross Cooper 210, Heathfield 202, Heathfield Physiology Web Page: Skills Web Page: Clinical Skills MOODLE: Please Note: Students who have had an educational assessment and require assistance or additional time for the assessment (Part B) MUST contact the Module Co-ordinators & Student Services, as soon as possible, for this to be arranged. 1

4 GM4078 Module Guide Faculty School/Department Course Health Nursing Studies and Women s Health Dip HE Nursing/ BSc Nursing Module title Core Nursing Skills and their Theoretical Frameworks Total study hours Student Directed Study: 72 hours Staff Directed Study: 168 hours Total = 240 hrs Level 4 Credit rating Double module- 24 credits L4. Tutor contact Stefan Cash Heathfield 221 Tel details Melanie Shale Heathfield 207 Tel Aims To introduce and support the development of a range of core nursing skills, transferable across all 4 branches, and to introduce principles of physiology and psychology that enhance and inform the development of these skills. Module Description The module will provide relevant principles of physiology and psychology to support the broad range of core nursing skills practised in this module. The module will cover fundamental issues of moving and handling, infection control and stress and coping. The physiology of cells and cancer, temperature control, and the respiratory, circulatory, digestive and renal systems will be covered and applied to relevant aspects of nursing skills such as observations, urinalysis, feeding, pressure sores and drug administration. Topics in psychology including anxiety and stress, communication, risky behaviours and bereavement will be covered and applied to relevant nursing skills. Moving and handling- anatomy of the vertebral column and forces acting on it. Posture, hoists, legislation, condemned manoeuvres. Infection control- micro-organisms and disease spread, hand washing, universal precautions. Stress and coping- personal stress inventory, short term and long term effects of stress, strategies for coping with bereavement. Communication- theory and practice Respiration- overview of system, control of respiration rate, assessment of respiratory function. Cells and Cancer- inherited and sporadic cancer, how cancer develops, smoking and cancer risk. Psychological factors, smoking as a health risk behaviour. Circulation- overview of the system, control of BP and pulse. Effects of stress, personality types. Digestion and nutrition- Overview of the system, diet and health risk. Diet and health risk behaviours. Assessment of nutritional status. Feeding patients. Renal system and dehydration- Overview of system. Causes and consequences of vomiting and dehydration. Pressure ulcers- causes of pressure ulcers, grading and prevention, body image. Temperature- Control of temperature and development of fever, temperature measurement and management. Urinalysis- How to carry out urinalysis and interpretation of results. Drug administration- Use of BNF, drug absorption, distribution and elimination, withdrawal, at-risk behaviour, Depression and anxiety- causes, health promotion and treatments 2

5 *Rationale The module aims to provide a foundation that can be used to develop a repertoire of skills during the initial placement. This will enable students to make a valid contribution to practice at an early stage of their career. A working knowledge of physiology and psychology underpins many of these skills. Learning outcomes Knowledge & Understanding Learning Outcomes (Tick as appropriate) Intellectual Skills Practical Skills Transferable Skills Demonstrate safe practice in placement by successful completion of F2.5 and F4.2. Describe how to carry out a range of core nursing skills and their application to practice. Explain the principles of physiology and their application to the core nursing skills. Explain the basic psychological principles and communication skills and their application to nursing practice. Learning and Teaching Strategy The module will be taught by formal lectures in introductory physiology, psychology and nursing theory, e-learning activities, videos, group work, team teaching, linked teaching, tutorials and practical skills sessions. Assessment Strategy The module will be assessed by an exam. Students must also pass their practice placement profile. 3

6 *Assessment Criteria The exam will test students ability to; Describe how to carry out a range of core nursing skills and their application to practice ( LO2), Explain the principles of physiology and their application to core nursing skills (LO3) Explain some principles of psychology and their application to nursing practice. (LO4) The practice profile will assess the ability to demonstrate safe practice in placement by successful completion of F2.5 and F4.2 ( LO 1) *Assessment dates October *Informed at Module Launch Related Modules Method of Feedback to students Students will receive an overall % mark for the exam. The practice profile will be assessed on a pass/fail basis. Learning Resources Refer to essential and recommended reading Access the following web sites: *Student Notes 4

7 Reading Lists Note that where a consensus exists skills taught will reflect local policy guidelines. PSYCHOLOGY READING LIST Edelmann, R.H. (2000) Psychosocial Aspects of the Prentice Hall, Health Care Process Harlow Naidoo, J. & Wills, J. (2000) Health Promotion Foundations for Practice Baillaire Tindall, London Ogden, J (2002) Health Psychology Open University Press Sarafino, E.P. (2002) Health Psychology biopsychosocial Wiley, New York. Interactions PHYSIOLOGY READING LIST Herlihy B & Maebins NK (1999) Human Body in Health and Illness WB Saunders Hinchliff SM & Montague SE (2000) Hubbard J L & Mechan, D J (1997) Marieb, E. N. (2004) Minett P, Wayne D & Rubenstein D (1999) Sherwood L (1997) Tortora G (2004) Physiology for Nursing Practice 2E Bailliere Tindall The Physiology of Health and Illness: with Related Antomy. Stanley Thornes. Human Anatomy & Physiology 6E. Benjamin/ Cummings. Health Studies Collins Human Physiology - from cells to systems: West Publishing Co. Introduction to the Human Body 6E Willey Tortora G & Grabowski SR (2006) Principles of anatomy and physiology 11E Willey NURSING SKILLS RECOMMENDED READING It is strongly recommended that you purchase a nursing dictionary for use both in your studies and whilst on placement. Baillie L (2005) Dougherty, L & Lister, S (Eds) (2004) Gatford, J.D. (2002) Developing Practical Nursing Skills. Edward Arnold Publishers Ltd, London The Royal Marsden Hospital Manual of Clinical Nursing Procedures 6 th ed. Blackwell Publishing, Oxford. Nursing Calculations 6 th Edition Churchill Livingstone Hogston, R. & Simpson, P.M. (ed) (2002) Foundations for Nursing Practice, 2 nd Ed Macmillan Press, London 5

8 Lapham,R. Agar, H. (2003) Terje Simonsen [et al.] (2006) Drug Calculations for Nurses A step by step approach 2 nd Edition Arnold London Illustrated pharmacology for nurses. Hodder Arnold, London NURSING SKILLS READING LIST Astor R & Jeffereys K (2000) Birmingham Children s Hospital NHS Trust (2000) Bindler R & Ball J (1999) Gates B (3rd edition reprinted in 2000) Gates B & Beacock C (1997) Goldsmith J Goldsmith L (1996) Goldsmith J Goldsmith L (1996) Holland K and Hogg C (2001) Lee, G. & Bishop, P. (1997) Positive Initiatives for people with Learning Difficulties; Promoting Healthy Lifestyles MacMillan Press Ltd Clinical Care Manual for Children s Nursing. Mark Allen Publishers ltd, Wiltshire Quick reference to pediatric clinical skills. Appleton and Lange, Connecticut Learning Disabilities Churchill Livingstone Dimensions of Learning Disability Bailliere Tindall (published in association with the RCN) Symmetrical body support: a carer s guide to the management of posture The Helping Hands Company, Ledbury Symmetrical body support: a therapist s guide to the management of posture The Helping Hands Company, Ledbury Cultural Awareness in Nursing and Health Care. Arnold, London Microbiology andinfection Control for Health Professionals. Prentice Hall, London The National Back Pain Association (1997) The Guide to the Handling of Patients. 4 th ed. Royal College of Nursing, Middlesex Thompson, T & Mathias, P Trounce, J.R. (2000) Webb M (1999) (7 th Ed) Wilson, J. (1995) Wondrak, R (1998) Standards and Learning Disability Bailliere Tindall 2 nd Edition (1998) (published in association with the RCN) Clinical Pharmacology for Nurses 16 th ed. Churchill Livingstone, Edinburgh. The Authorised Manual of St John s Ambulance. Dorling Kindersley, London Infection Control in Clinical Practice. Balliere Tindall, London. Interpersonal Skills for Nurses and Health Care Professionals, Blackwell Science, London. 6

9 Learning resources for Health and Community Care students 1. Physiology modules Links that take you to materials related to Physiology modules, including module guides, lecture notes, information on assessment, test results etc. 2. Basics of human physiology. If you have never studied physiology before (or your physiology's a bit rusty), this page supplies downloadable information sheets on introductory topics such as diffusion, cells and homoeostasis. 3. Key concepts of human physiology. These are downloadable files that can help you understand important areas such as blood pressure, inflammation control of blood glucose and fluid balance. 4. Links to external sites for free information on physiology and medicine. 5. Online Quiz. Test your knowledge of basic physiology - try it out! Lots of useful material and links relating to nursing clinical skills including handouts and booklets, quizzes and staff contacts. You can access the Physiology and Skills Team Websites from any Internet-linked computer, from UCE Student computers or from your home computer. Log on, open up Internet Explorer and type in the address field 7

10 Section1 Session 1: Introduction to the workbook In an attempt to make a stronger, more obvious link between physiology and nursing skills both a physiologist and a nursing lecturer will deliver most of the tutorials. A physiologist or psychologist will deliver the lead lectures. This workbook contains be key information, pre-reading, questions, recommended further reading and self-directed activities for each subject area. Self-Directed Activity To ensure that you get the best from each session in this module, it will be your responsibility to complete the self-directed study tasks that are outlined in the workbook. Many of these tasks request that you complete study materials prior to attending a specific lead lecture or tutorial. Often, the focus of the proceeding session will include discussion or use of the work that you have been required to complete. If you require additional support with a specific task, please contact a tutor in the relevant subject area (i.e. nursing skills, physiology or psychology) for assistance. Please ensure that you bring your workbook along to all of the sessions. Frequently asked questions - Please refer to FAQ on the Physiology Website Skills sessions Alongside the tutorial sessions, students will also have practical sessions relating to basic life support & manual handling (compulsory) injections, communication skills, observations, optional hygiene & skills practice. Please remember you will NOT be allowed out on placement if you have not completed the Manual Handling skills session or Basic Life Support skills session. You will not be allowed into these sessions if you turn up late. For the Blood Pressure skills session please wear clothing that will allow easy access to the upper arm, as you will be practicing BP measurement technique on each other. For the Nutrition and Feeding skills session you are required to bring some sloppy food e.g. Yoghurt and spoon. 8

11 Session 2: Moving and Handling Moving and Handling: General Information Over the next three years you will attend regular manual handling sessions. The purpose of these sessions is to reduce the risk of back injury to yourselves, your colleagues and the patients as much as is reasonably practicable. All sessions are mandatory and are a legal requirement (MHOR 1992, as amended 2004) Please wear flat supportive shoes. No jewellery. No chewing gum Trousers that allow for movement Hair tied back If you arrive inappropriately dressed, you will be required to come back on another day and time. If you are unable to attend the session due to sickness you must contact: - John Hatfield, Admin: , e mail: Failure to attend for training will result in you not being able to commence placement. As trainers the optimum student trainer ratio is 1:7 so it is very important that you stick to the group you have been allocated to. The moving and handling training is carried out in room 035/036 Bevan House. Look on CELCAT. Introduction Moving and handling is an integral part of our lives whether inside or outside the work environment. It is essential that we minimise the risk of injury to ourselves, our colleagues and patients to the lowest reasonably practicable level. The moving and handling team at UCE have all undertaken recognised training courses enabling them to train others in moving and handling, and are committed to helping you to develop your skills in this important area of care. Training is underpinned by the Manual Handling Operations Regulations (MHOR 1992 as amended 2004) and utilises the theories of human kinetics* and ergonomics*. Throughout the course you will be developing skill in:- Using certain moving and handling techniques and equipment Analysing your own movement and posture Observing and analysing the movement and posture of your colleagues Using assessment tools and participating in problem solving exercises Recognising the impact of moving and handling on patients and clients Identifying the importance of legislation and codes of practice in helping us to develop and implement best practice If you have any concerns while in practice about being able to comply with what you have been taught, please seek advice from:- The trust policy for moving and handling Discuss your concerns with your assessor or unit manager Any of the moving and handling team at UCE The moving and handling advisors from the trust Do not under any circumstances participate in any of the condemned manoeuvres. *Human Kinetics:- Moving and handling in the most efficient way with the least amount of effort *Ergonomics:- Adapting the environment to suit the person not the other way around. 9

12 Legislation Relating to Manual Handling 1. Manual Handling Operations Regulations 1992 (Amended 2004) 2. The Management of Health & Safety at Work Regulations Regulations 5 to 27 of the Workplace (Health, Safety & Welfare) Regulations Health & Safety at Work Act Provision and Use of Work Equipment Regulations Lifting Operations and Lifting Equipment Regulations Human Rights Act 1998 Employers Responsibility Health & Safety at Work Act 1974 Employers are responsible for the Health, Welfare and Safety of their employees, and must provide information, instruction, supervision and training for them. Manual Handling Operations Regulations (1992) (Amended 2004) Employers are responsible for:- 1. Avoidance of manual handling down to the lowest level reasonably practicable; 2. Assessment of Risks; 3. Reduction of any identified risks down to the lowest level reasonably practicable; 4. Provision of information on the load; 5. Review of risk assessments. In determining for the purposes of this regulation whether manual handling operations at work involve a risk of injury and in determining the appropriate steps to reduce that risk regard shall be had in particular to a. The physical suitability of the employee to carry out the operations; b. The clothing, footwear or other personal effects he is wearing; c. His knowledge and training; d. The result of any relevant risk assessment carried out pursuant to regulation 3 of the Management of Health and Safety at Work Regulation 1999; e. Whether the employee is within a group of employees identified by that assessment as being especially at risk; and f. The results of any health surveillance provided pursuant to regulation 6 of the Management of Health and Safety Regulation The Management of Health & Safety Regulations 1992 Reg.5: Deals with the maintenance of the workplace, equipment, devices and systems to ensure that they are in good repair and efficient working order. Regs.6,7,8 and 9: Deals with ventilation, temperature, lighting and cleanliness. Employees Responsibility Health & Safety at Work Act 1974 Section 7: The employee is responsible for his own health, welfare and safety his acts and omissions and must cooperate with the employer in order for him to comply with his health and safety duties Manual Handling Operations Regulations (1992) (Amended 2004) Regulation 5:-The employee must make use of safe systems of work provided by the employer. The Management of Health & Safety Regulations 1992 Regulation 12:- The employee must use equipment machinery and aids in accordance with the training and instructions of the employer. 10

13 Manual Handling and the Human Rights Act Which statement is correct? 1. I have a right not to suffer the indignity of being put in a hoist says a client. 2. I have a right to refuse to lift heavy clients without the necessary equipment says a carer. Article 3. No one shall be subjected to torture or to inhuman or degrading treatment or punishment. Article 5. Right to Liberty and Security Everyone has the right to liberty and security of person. No one shall be deprived of his liberty save in the following cases and in accordance with a procedure prescribed by law. It is clear that using a hoist could temporarily deprive a person of their liberty. However since the person in the hoist would be fairly immobile we are talking about one restriction of freedom of movement. Article 8. Right to respect for private and family life Everyone has the right to respect for his private and family life, his home and his correspondence. This could become relevant if a threat was made to remove a person into a nursing home if they refused to use a hoist. It could be argued that they had a right to remain in the family home. The Nursing Standard Volume 18, No 21 (February ) page looks at manual handling and the lawfulness of no-lift policies following recent coverage of the plight of a woman who spent a year sleeping in her wheelchair because the local NHS trust refused to allow her to be lifted into bed Individual Assessment An acronym to remember is ELITE E: Environment L: Load I: Individual Capability T: Task E: Equipment Environment. Are there Load. Is it - Space constraints preventing good posture. Poor flooring Differing work heights Extremes of temperature or humidity Poor ventilation Gusts of Wind Poor lighting Individual capability. Does the job Require unusual Strength Height Knowledge Skill Create problems for those with health problems e.g. pregnancy Require special information or training Equipment. Fit for purpose Designed to reduce or avoid the need for manual handling Easy to move, adjust and maintain A range of aids to suit the needs of your client group, and in enough quantity Ref: MHOR (1992) Heavy Unwieldy Difficult to grasp Unstable Moveable contents Sharp Hot / Cold Potentially dangerous Task. Do they involve Holding or manipulating loads at a distance from the trunk Unsatisfactory bodily movement or posture especially twisting, stooping or reaching upwards Excessive load movement Large vertical movement Carrying long distances (10m) Other factors Is movement or posture restricted by protective clothing Multi tasking A good working atmosphere 11

14 Condemned Manoeuvres Dangers to the patient It hurts the patient It contributes towards the formation of pressure sores The patient can be dropped and injured It discourages the patient from mobilising The drag lift The orthodox / cradle lift Dangers to the patient When nurses push their arms through sensitive skin can be damaged The nurse s arms are relatively narrow and unpadded. The weight of the patient is taken on a small part of the patients skin which again may damage sensitive skin Dangers to the patient Does not allow for normal range of movement Can pull on the axilla Dangers to the patient Part of the pull is under the patients axilla and will cause pain Bear hug / Clinging ivy Through arm lift The Australian or shoulder slide Dangers to the patient The forward bend in the body is not suitable for patients with chest or abdominal wounds, or after hip surgery. The force of the nurse s shoulders on the chest wall can cause breathing difficulties. It can be painful for patients with arthritis Dangers to the nurse The lift creates a shearing force across the shoulders The load is taken at a distance from the base of the spine The lift involves a twist The patient tends to rely upon the nurses for all support The nurses have difficulty lowering a patient who collapses Dangers to the nurse You are in a top heavy bend The lifters can easily move outside their centre of balance and twist in the final stages of the lift Dangers to the nurse If a patient fails to stand or collapses in this position the whole of their weight will come onto the nurses neck Dangers to the nurse The lift is operating a long way away from the base of the spine Dangers to the nurse There is uneven loading across the nurses shoulders causing significant strain on shoulder joints The arm holding the sliding sheet is at a awkward angle, and may cause pain and damage For more information on condemned manoeuvres see The Guide to Handling of People, 5 th Edition (2005) edited by Jacqui Smith and published by BACKCARE in collaboration with the Royal College of Nursing & the National Back Exchange. Psychological effects of poor handling Anger at rough handling Non cooperation due to fear of mishandling Antagonism due to lack of communication Patients feelings of helplessness can cause feelings of depression and withdrawal Patients experience a loss of dignity and feel isolated 12

15 The principles of safe moving and handling Avoid moving and handling of loads where possible If you cannot avoid, assess ELITE Reduce the risk of injury by choosing the correct equipment, number of staff and suitable technique. Review success of the manoeuvre. Communicate effectively with the client Prepare the area. One person should take the lead and be responsible for giving commands. E.g. ready? yes, set, slide. Using the command is ambiguous and recognised as an unsafe system of work by the Health and Safety Executive, so therefore should not be used. Have a wide base, suitable to the manoeuvre Unlock the knees Avoid twisting and a top heavy bend Keep the load close Lift within your centre of gravity The head leads all movement Use a transfer of body weight to accomplish the move, using strong thigh muscles. Avoid using individual groups of muscles such as in the arm as these are weak and the manoeuvre will then be relying on strength not good technique. The Falling patient If the patient is collapsing and cannot be persuaded to stand he must be lowered to the ground immediately. On no account try to support the patient s weight. Nursing actions Release hold of the patient Move behind the patient Open hands and takes one step back Allow patient to slide to the floor Let the patient remain in the sitting position on the floor (if conscious) It is important to plan for this eventuality and therefore the patient should not be supported or held in any way, which prevents the nurse from releasing their grip. The nurse should also avoid any method which allows the patient to grab hold of the nurse in the event of falling The nurse must not rush to rescue a falling patient, you will not be close enough to get into position in time. Once the patient is ready to be moved off the floor, there are only three options that can be considered:- Guide the patient to get up himself Lifting using a hoist Lifting using an inflatable system Do not rush to get the patient off the floor Assess for injuries NBPA & RCN

16 Hoisting When would you use a hoist? As often as you can to avoid lifting patients Whenever moving non weight bearing or frail patients Features that may be available on the hoist:- Foot control to open and close base struts Hand held control unit Battery spare must always be on charge Emergency button in case of battery failure Identified weight limit Brakes- there may be specific instructions from the manufacturer about using the brakes. A number of hoists require the brakes to be off when raising or lowering. A hoist is not automatically safe Using a hoist may be a two person procedure You may have to manoeuvre the hoist around tight corners. You need specific instruction in using different makes of hoist Roll or sit the patient forward to position the sling. Don t be tempted to lift Considerations when using a hoist Brakes-to use or not? Type of flooring Type of hoist and sling Patients capabilities, E.G suitability for standing hoist and their confidence with the hoist Access under and around furniture Space occupied by the hoist Pushing and pulling issues There are many issues regarding hoists and slings and these must be considered within the whole safer handling strategy of an organisation and correct management applied equally & separately to the hoists and slings. Considerations for moving and handling people who become aggressive Wait rather than rush in Seek to calm a situation Adopt an encouraging and reassuring manner Call for or await arrival of help Look at their risk assessments and care plan Discuss approaches with the team you are working with Confused or frightened patients Patients need to feel calm and safe Be sensitive to mood and non verbal signals If anxious they may feel crowded and want to hit out This may be caused by sensory loss and disorientation Some flooring can create visual impressions. Space in a ward can seem so immense as to be impassable Big blocks of colour may appear as barriers which stop the patient in their tracks A gentle slope may seem like a precipice. Failing eyesight and deafness may be a problem Reference: (RCN, NBPA 1999) 14

17 Additional Considerations for manual handling people with Learning Disabilities People who use wheelchairs / People in moulded wheelchairs. Difficulty in placing hands underneath person results in poor grip, difficulty in using lifting aids, difficulty in placing slings underneath client for hoisting Managing continence needs and maintaining an infection free environment Sensory deficits can lead to the person displaying challenging behaviour as a means of showing that they do not know what is happening to them spend time letting the person feel the equipment if they can not see it. Motor deficits many people with learning disabilities have mobility deficits and an unsteady gait. They also may suffer from stiffness in their joints and muscles from lack of movement being moved or hoisted straight away (i.e. first thing in the morning before they have woken properly) may cause them pain. The environment. Can you push the wheelchair easily in and out of the home/room? Is a ramp needed? Are the carer s using appropriate methods of manual handling for this person? Additional Considerations for manual handling other branches Are the carers using appropriate methods of manual handling for this person? Especially child branch can you arrange for them to have training? References Smith, J (ed) (2005) The Guide to the Handling of People. Published by Back care, Royal College of Nursing & the National Back Exchange HSE (2004) Manual Handling Operations Regulations 1992 (as amended) Guidance on Regulations. The Stationary Office, London. HSE (1998) Manual handling in the Health Services, HMSO, London HSE (1998) Manual Handling Operations Regulations 1992, guidance on regulations, HMSO, London HSE (1998) Lifting operations and lifting equipment regulations 1998, HMSO, London Interesting websites 15

18 Anatomy of the Spine ANATOMY & PHYSIOLOGY IN RELATION TO MANUAL HANDLING By the end of this session you should be able to: Explain how muscles are used to move the vertebral column. Describe how correct lifting techniques reduce strain on back muscles and joints. Discuss types of back injury that may occur due to poor manual handling. The Skeletal System Protection, movement, support Upright posture Axial skeleton Skull, vertebral column, thorax Appendicular skeleton Bones of limbs and girdles Joints, cartilage, ligaments. ROLE OF THE SPINE MOVEMENT Many individual, moveable bones make up the spine. RIGIDITY / SUPPORT The pelvis is a solid base to which the spine is attached. The bones of the spine are bound by inelastic ligaments. TYPES OF VERTEBRAE 1. CERVICAL (Neck) - very flexible 2. THORACIC (Thorax) - inflexible 3. LUMBAR (Lower back) very flexible 4. SACRUM & COCCYX (Attached to pelvis) fused together. The most flexible areas of the spine are most often injured. Why? 16

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20 Moving the spine Spinal Nerve Intervertebral Disc Lumbar vertebra Back muscles Contract to maintain upright posture Contract to pull the spine backwards. Abdominal muscle contract to bend spine forwards. Muscle weakness- lack of exercise Obesity Question. What is the difference between Lordosis and Kyphosis (curvatures of the spine)? Lifting Objects Bend your knees rather than your back to lift objects Weight is transmitted to legs rather than back If you bend your back to lift a heavy object Back muscles must lift upper body AND object May damage muscles May damage joints, especially lumbar vertebrae. 18

21 Spinal movement and forces The Spine is subjected to a number of forces when we move, all of which can potentially cause damage and pain: Compressive - vertebrae are squeezed together. Tension - vertebrae are pulled apart. Shear - vertebrae moved in different directions (side to side). This can happen in football and car accidents. Torsion vertebrae are twisted in opposite directions. 19

22 SPINAL MOVEMENTS & FORCES Compressive - vertebrae are squeezed together. Tension - vertebrae are pulled apart. Shear - vertebrae moved in different directions (side to side). Torsion vertebrae are twisted in opposite directions. RISK FACTORS FOR BACK INJURY PRIOR INJURY AGE (Older) GENDER (Women) OVERWEIGHT SEDENTARY / UNFIT WHY??? T A L L STRESS UNEVEN WEIGHT DISTRIBUTION MUSCLE WEAKNESS POOR POSTURE HIGH HEELED SHOES HEAVY LOAD Sprained ligaments Ligaments limit joint movement Damaged if overloaded by overstretching, twisting and bending. Severe sprains May damage or tear ligaments Ligaments heal but may be scarred and become weaker Further injury may occur Strained muscles Muscle is contracted beyond it s limit Mild strain involves little damage Severe strain may be due to muscle tear Healed muscle may be scarred and weakened More prone to further injury Muscle spasm protective to prevent further damage Regular exercise strengthens muscles warming up Question What is the difference between a ligament and a tendon? Damage to intervertebral discs Slipped, ruptured, bulging or herniated discs Intervertebral disc bulges between the vertebrae material can leaked from disc Lumbar and cervical discs most commonly affected Disc may press on spinal cord Localised pain May also affect buttocks, legs, feet. Sciatica 20

23 Session 3: Infection Control Self-Directed Activity The first 3 pages of this session should be carried out as part of your own private study. Read the following background information and then answer the questions prior to the skills session (the answers will not be provided here). If you have any difficulties, please see a physiology tutor. The spread of disease. Infectious diseases can be spread in a number of ways. There are 3 main categories that summarise how diseases can be spread. Direct Contact Transmission: - This involves the direct contact of the person with the infected material such as touching, kissing or sexual contact. Infections can also be spread directly coming into contact with infected droplets produced during sneezing. This only occurs if the droplets are large enough to carry the infection and only travel over short distances of less than a meter. Indirect Contact or Vehicle Transmission: - Here inanimate objects are involved in the spread of the disease and are called vehicles. Examples of vehicles include money, drinking and eating utensils, books and bedding. Vector Borne Transmission: - Vectors are animals that carry the infection. They can be insects, ticks, fleas and mites, but can also be dogs, cats, skunks and bats. The following microbiology notes are supplied on pathogens and diseases, which may also help you answer some of the questions below. Food Poisoning There has been a dramatic increase in the incidence of food poisoning in the last few decades. Even more alarming is the emergency of particularly virulent strains of pathogens. These include E. coli 0157, which seems to favour poorly prepared meat. This organism releases toxins that destroy gut and kidney cells and result in painful (and sometimes fatal) bloody diarrhoea. In 1996 there were 20 deaths in Lanarkshire linked to undercooked beef burgers. Other common food poisoning pathogens include Listeria monocytogenes, which is particularly fond of unpasteurised soft cheeses and can be dangerous in pregnant women. Two very common bacteria are Salmonella and Campylobacter that can contaminate meat and dairy products. The very young and the very old are those most at risk, plus those who are already sick and immunocompromised. Bacteria also grow very quickly and so food should be served as fresh as possible, when this is not possible refrigeration or freezing should be used to slow down and reduce bacterial growth. Athletes Foot Athlete s foot (inea pedis) is a common, superficial skin infection of the foot caused by mould-like fungi such as Trichophyton- the disease is often referred to as ringworm. The fungi thrive in warm, moist places so they are frequently a problem for people who exercise or do not observe foot hygiene. The condition is contagious and can be spread by direct skin-to-skin contact and indirectly through towels, shoes, floors, etc In its most common form, athlete s foot appears as red itchy rash in the spaces between the toes and possibly small pustules and scaling. The infection can spread to the rest of the foot and other parts of the body. The infection can also infect toenails. The nails and nail bed thickens, discolours and the nail may eventually be destroyed. Fungal infections often take longer to treat as the fungus is made up of cells similar to those found in the human body, therefore aggressive treatments cannot be used, as whatever can kill the fungi will also kill our own skin cells. Therefore fungal infections often take longer to be treated. 21

24 Cold Sores Cold sores are very common disease caused by Herpes simplex virus type 1 (HSV-1) that is transferred between individuals by intimate contact such as kissing. The disorder is characterised by groups of fluid filled blisters that appear on red swollen areas of the skin or on the mucous membranes. The areas can be tender and painful. The blisters heal without scarring but have a tendency to recur if there is a weakening of the body s defences, due to severe cold for example, can lead to a reactivation of the virus and return of the blisters Sexually transmitted diseases (STDs) Sexually transmitted diseases (STDs) are among the most common infectious disease in the United Kingdom today. More than 20 different STDs have been identified, and depending on the disease, these infections can be spread with any type of sexual activity involving the sex organs, the mouth, or contact with blood. STDs can be bacterial, viral or fungal. STDs include Chlamydia-the most common and fastest spreading sexually transmitted disease in the UK. Other common STDs include gonorrhoea, genital herpes and syphilis. Thrush, not strictly a STD is a common fungal disease caused by Candida albicans. It can be spread by sexual contact. HIV/AIDS is potentially lethal sexually transmitted diseases and is caused by the HIV virus. HIV invades and destroys the immune system, which protects the body from infection. A person who carries the HIV virus is prone to many different illnesses and may die from Diseases that are harmless to healthy people. Antibiotic actions Antibiotics are used to treat bacterial infections and they work in a variety of ways. Penicillin works by weakening the bacterial cell wall causing it to break open, killing the bacteria; it also prevents the bacteria reproducing. Antibiotics are not effective at treating fungal or viral infections. This is why they should not be prescribed for a cold, as they are not effective at treating viruses. Some bacteria develop resistance to antibiotics, this can happen in a number of ways. First of all some bacteria may naturally survive the antibiotic treatment due to natural selection. These resistant bacteria can then go on to reproduce a new resistant population of bacteria. The other method that bacteria can develop resistance by is plasmid transfer. Here bacteria are able to swap genes between members of the same or even different species that promote resistance. In this way antibiotic resistance can spread quickly among different bacteria and the antibiotic is no longer effective at treating the bacterial infection. MRSA MRSA-methicillin resistant Staphylococcus aureus is a gram-positive coccus that is common and is generally non-pathogenic in healthy people. However, it can be more dangerous to sick people (especially those found in hospital) where it can cause septicaemia and pulmonary problems. Unfortunately, some populations of S. aureus have developed resistance to common antibiotics, including methicillin (now discontinued), which used to be the antibiotic of choice. In the past year or so, there have been reports of a new strain of S. aureus emerging that are also resistant to vancomycin, one of the few remaining antibiotics that can treat MRSA. Fever Fever is the body s defence mechanism against either viruses or bacteria. The body produces prostaglandins as a response, which acts to increase body temperature. The body tries to create so much heat that the virus or bacteria cannot survive so having a temperature helps fight illness. The hypothalamus, the part of the human brain that controls body temperature is not fully developed in children so their temperature may rise and fall quickly. Often a child running a temperature may only be suffering from a minor infection but needs observing as other symptoms such as vomiting or diarrhoea, stiff neck, dyspnoea etc. could indicate that the illness is more serious and needs proper medical attention. For mild fevers paracetamol is given to adults and the child version of paracetamol Calpol to children. It is believed to treat the fever by reducing the production of prostaglandins, therefore returning body temperature to normal. 22

25 Answer the following questions 1. Read through the 3 categories above that describe how diseases are spread. Place each statement from the list a-l in the correct category. Some statements may fit more than one category. a. Food infected with E. coli b. Mosquito carrying the malarial parasite bites someone c. Person infected with tuberculosis (TB) sneezing close to a baby d. Spread of HIV/ AIDS e. Drinking from an unwashed mug, containing traces of saliva from someone who had flu f. Not washing hands after going to the toilet, and then shaking hands with someone g. Ring worm causing Athletes foot h. Reusing unwashed bedding in a hotel i. Flies in contact with uncooked meat j. Reusing an unsterilised thermometer k. Handling faeces and urine without gloves l. Spread of cold sores 2. Most bacterial infections can be treated using modern antibiotics. Suggest why MRSA is such a problem, particularly in hospitals. 3. Antibacterial antibiotics have revolutionised the treatment of infections. Why would it be inappropriate to prescribe antibiotics for a cold sore or for athlete s foot? 4. If food is prepared the previous day and left un-refrigerated. Why might the people who eat it be at risk of food poisoning? 5. If someone has a sore throat and high fever, why is it inappropriate to share a drink from the same cup or kiss them? How might we treat a mild fever in adults and children? Now you have completed the above questions, please 1. View the video lecture (Correct hand cleansing technique minimising cross-infection) by Norman Rickard, from the following web address: 2. Read the following article: Rickard N. A. S. (2004) Hand Hygiene: promoting compliance among nurses and health care workers British Journal of Nursing 13(7)

26 Infection Control - Skills notes The cost of nosocomial infections to the NHS in 1992 was an estimated 110 million (Chapman et al. 1993). It has been estimated that a reduction by one fifth of the UK nosocomial infection rate of 5% would save the NHS 15.6 million (Chaudhuri 1993) A survey of factors, which influence compliance with infection control procedures, highlighted lack of knowledge, lack of time and shortage of staff and the standard set by senior staff including surgeons and nurses (Sherwood 1995) It has been estimated that an infected patient has an average increased hospital stay of 17 days and average increased costs of 2220 (O'Donoghue & Allen 1992), emphasizing how important it is to prevent infection. The risk of infection is increased if the patient is immunocompromised by: Age: Neonates & the older adult have an increased risk due to their less efficient immune systems Existing disease e.g. malignancy, severe viral illness e.g. HIV. Drug therapy the use of immunosuppressive drugs or the use of broad-spectrum antimicrobials. Patients undergoing surgery or other invasive procedures e.g. catheterisation. (Hart 1990) The most usual means for spread of infection include: Hands of staff Inanimate objects e.g. clothing, cutlery, cups & baths. Airbourne particles of dust and / or droplet nuclei. Hand washing Hand washing is well researched and has been found to be the single most important procedure for preventing nosocomial infection. Hands have been shown to be an important route of transmission of infection (Casewell et al. 1977) even brief contact can transmit colonyforming units to hands (Gould 1993) Wearing rings, wristwatches and other jewellery increases the number of micro-organisms on the hands (Jacobson et al. 1985). However, research has shown that hand washing is rarely carried out in a satisfactory manner (Taylor 1978) In addition these studies have highlighted that up to 89% of staff miss some part of the hand surface during hand washing (Taylor 1978) Area s most commonly missed following hand washing. 24

27 Hands should be washed with soap and water before any direct contact with patients or clients and in particular: Before and after handling invasive devices e.g. catheters, cannulae and NG tubes. Before and after dressing wounds Before and after contact with immunocompromised patients. Before and after preparing and handling food & drink After handling equipment contaminated with body fluids After contact with blood or body fluids After handling clinical waste and used laundry After removing gloves After using the toilet Before leaving the clinical area or a client s home. (Wilson 2002) Procedure for hand washing: 1. Wet hands thoroughly, before applying detergent or cleansing agent. 2. Rub palm to palm. 3. Rub right palm over left dorsum and left palm over right dorsum. 4. Rub palm-to-palm fingers interlaced. 5. Rub the backs of the fingers to opposing palms with fingers interlocked. 6. Rotational rubbing of right thumb clasped in left palm and vice versa 7. Rotational rubbing back and forwards with clasped fingers of right hand in left palm and vice versa. 8. Rotational rubbing of each wrist. 9. Rinse and dry hands thoroughly. Infection control is not just about hand washing, there are other ways of reducing the risk of cross infection which you will explore using the resources provided. Apply the principles of infection control that you have identified to a clinical setting and answer the following questions using the resources available: 1. When should you wash your hands? 2. What are Universal precautions? 3. When should gloves be worn? 4. What other protective items can be worn and when would you use them? 25

28 5. What are the important principles when handling needles to prevent needle-stick or inoculation injury? 6. How should you care for your uniform or clothing worn in the clinical area? 7. How should you deal with spillages of blood or other body fluids? 8. What is clinical waste? 9. What colour are the rubbish bags for clinical waste? 10. If bed linen is visibly soiled what do you do with it? 11. What does Nosocomial mean? 12. What is source isolation? References: Chapman R. et al Surveillance and feedback of hospital acquired infection rates in the USA. Public Health Lab Services, Microbiology Digest, 11(1), 35-7 Chaudhuri A.K (1993) Infection Control in hospitals: has its quality enhancing and cost effective role been appreciated? Journal of Hospital Infection, 25, 1 6. Sherwood E. (1995) Motivation the key factor. Nursing Times. 91 (20), O Donoghue M.A.T & Allen K.D (1992) Cost of an outbreak of wound infections in an orthopaedic ward. Journal of Hospital Infection, 22, Hart S. (1990) The immunosuppressed patient in infection control, cited in Guidelines for Nursing Care, eds: Worsley M.A et al. pp Surgikos Ltd. Casewell M et al. (1977) Hands as a route of transmission for Klebsiella species. British Medical Journal, 2, Gould D (1993) Assessing nurses hand decontamination performance. Nursing Times, 89 (25), Jacobson G. et al (1985) Handwashing: ring-wearing and number of microorganisms. Nursing Research, 34(3), Taylor (1978) An evaluation of hand washing techniques 1. Nursing Times, 74 (2), Wilson J (2002) Infection Control in Clinical Practice. London, Bailliere Tindall pp

29 Session 4: Psychological Aspects of Stress & Coping Preparation for Tutorial: Self-Directed Activity The aim of this session is to introduce the student to the relationship between stress and ill health. A small amount of stress is quite healthy, but when we find events in our life difficult to cope with, the levels of stress our bodies generate can start to have a detrimental impact upon our physical and mental well being. We can usually find ways of coping with this impact; we all have a range of coping mechanisms, some more healthy than others. Unhealthy, or inappropriate ways of coping also contribute to illness (e.g. smoking as a form of relaxation). Our personality and our upbringing can also have an impact upon our health, as these aspects determine our ability to learn how to manage stressful situations. Exercise Complete the Life Events Inventory. This may take some time, so allow yourself about 30 minutes. Be prepared to answer some personal questions about your life, but be honest. This will be strictly confidential. LEI Life Events Inventory The following list contains events that can happen to almost anybody in their lives. Please look at each event and think carefully about if it has happened to you in the last six months. If a particular event did happen to you, tick the box to the left of that event. At the end, total up your score, this will be discussed in the tutorial. You may access the article from which this scale was developed on the website (see reference below). Spurgeon.A., Jackson,C.A., and Beach,J.R. (2001) The Life Events Inventory: Re-scaling based on an Occupational Sample. Occupational Medicine: 51(4) p Male Female Unemployment (of main earner in the family) Trouble with superiors at work New job in the same line of work New job in new line of work Change in hours or conditions in present job Promotion or change of responsibilities at work Retirement Moving House Purchasing own house (taking out mortgage) New neighbours Quarrel with neighbours Income increased substantially (25%) Income decreased substantially (25%) Getting into debt beyond means of repayment Going on holiday Conviction for minor violation (e.g. speeding or drunkenness) Jail sentence Involvement in physical fight Immediate family member starts drinking heavily Immediate family member attempts suicide

30 Immediate family member sent to prison Death of immediate family member Death of close friend Immediate family member seriously ill Gaining of new close family member Problems related to alcohol or drugs Serious restriction of social life Period of homelessness (hostel or sleeping rough) Serious physical illness or injury requiring hospital treatment Prolonged ill health requiring treatment by own doctor Sudden and serious impairment of vision or hearing Unwanted pregnancy Miscarriage Abortion Sex difficulties Marriage Pregnancy (or of wife) Increase in number of arguments with spouse /partner Increase in arguments with other immediate family members Trouble with other relatives (e.g. In-laws) Son or daughter left home Children placed in care of others Trouble or behaviour problems in own children Death of spouse Divorce Marital separation Illicit sexual affair outside of relationship / marriage Break up of affair Infidelity of spouse / partner Marital /relationship reconciliation Spouse / partner begins or stops work Break up with steady boyfriend or girlfriend Problems related to sexual relationship Increase in number of family arguments (e.g. with parents) Break up of family

31 Stress Is modern life really rubbish, or are we all just complaining too much? Dr. Craig Jackson Senior Lecturer in Health Psychology School of Health and Policy Studies Faculty of Health & Community Care University of Central England hcc.uce.ac..ac.uk/craig_jackson Biopsychosocial model of Illness Hazard Psychosocial Factors Attitudes Behaviour Quality of Life Illness (well-being) Acknowledges psychological root of illness Ill-health is not just diseased vs well Acknowledges psychology can predict hazard exposure craig.jackson Potential Health Risks High Effort Low Reward Responses to Stress 3x Cardiovascular problems High Demand Low Control Physiological changes Heart rate Blood pressure Biochemical > adrenaline > cortisol > serotonin > free histamine 2x Substance abuse 3x Back pain 2-3x Injuries 2-3x Infections 5x Certain cancers 2-3x Conflicts Psychological changes Anxiety Apathy Depression Apprehension Tension Alienation Tired Resentment Worry 2-3x Mental health problems Confidence Indecision Aggression Sleeping problems Withdrawal Concentration Restlessness Shain 2001 Stress Golden Age of Stress Stress is Nothing New World Wars I and II Everyone is Stressed???? Where was stress? BBCi - Stress = 16,000 finds Dud shell manufacture More people experiencing more stress Greater demands from employers People working longer hours 24 / 7 / 365 society 29

32 Some Stress is good Keeps one alert Keeps one alive performance Evolutionary perspective: Too little stress = extinction Too much stress = extinction Balance stress = evolution Pressure is good - - Stress is bad stress Stress Statistics 1995: Labour Force Survey 1996: Institute of Management 515,000 reported work-related related stress 250,000 attributions of physical symptoms 30% increase in reports since ,000 daily absences for stress 10.2 Billion cumulative annual cost (sick pay, lost production, treatment) 2002: UK Health and Safety Executive 265,000 new cases in : Evans et al. Scottish heart attack deaths higher on Mondays 2004: UK Health and Safety Executive 13,000,000 working days lost / year 12 Billion cost Individual Variability / Vulnerability Vulnerable People Differing Attitudes & Differing perceptions Natural differences Complex reasons Experience Learned behaviours Personality Stress is associated directly with workplaces BUT is also mediated by individual differences No universal profile of what will certainly constitute stressful situations Important to be aware of vulnerable individuals and groups Associated with socio-economic economic, cultural or demographic status Females Immigrant workers Disabled Excluded groups Ethnic minorities Any group by definition which is un-empowered Personality although some of this is spurious! Type A (uptight, goal oriented) likelihood of stress-illness and CHD (?) Type C (high anxiety) likelihood of Cancer (?) Type D D (negative affectivity, emotional inhibition) likelihood of CHD (?) External locus of control poorer at handling stress Hardiness greater resistance and operability Historical Errors of Stress-Related Related-Ill Health Historically, stress was blamed for many ills Now we know better CHD Cholera Pellagra Beri Beri Asthma Down s syndrome Scurvy Yellow fever Typhoid Peptic ulcer William Beaumont 1832 All believed to be caused by stress or unhappiness at one time or another Puts blame for illness on the person Acute Stress and Chronic Stress Common After-effects Leave behind Life threatening One-off Ever-present By proxy Acute Acute Acute Acute Acute Chronic Acute Acute stress is fearful associated with loud noises or danger and peril Chronic stress is mundane associated with persistent annoyance or unpleasantness 30

33 Psychosocial Hazards Commonplace consideration in last 5 years Not straightforward All workplaces have potential to expose workers to psychosocial hazards All social relationships have potential for stress Little relation between stress incidents and occupational status Chronic Hazards Job content Work overload / underload Hazardous conditions Under utilisation of skills Time pressures Lack of control Work organisation Shift work Working hours unsociable long unpredictable Stress-Boom in last 3 years VERY BIG INDUSTRY Intolerance of work in environments deemed psychologically stressful suffering from & recognising stress rapidly increasing issues Work Culture Communication Change / technology Poor resources No feedback No decision process too little (home-working) / too much ( ) Chronic Hazards (cont) Legal Aspects Work role Ambiguity Conflict Advancement structure Insecurity Promotion under and over Low status Poor pay Environment Hazards physical / chemical Home work interface Conflicting demands Support Domestic problems Commuting Interpersonal Conflict Colleagues Superiors Subordinates Personal Issues Isolation Lack of support Harassment Bullying Violence Personal Injury Any impairment or any disease of a person s physical or mental conditionc 1974 Health and Safety at Work Act Assessments of risks of activities associated with potential hazards 1992 Management of Health & Safety at Work Regulations Big stress cases 1. Johnstone vs 2. Walker vs 3. Jones vs 4. Hurley vs 5. Fearon vs 6. Armstrong vs Bloomsbury H.A Northumberland C.C. Birmingham C.C Gwent Constabulary Martin Home Office Doctor Social Worker Teacher Police officer Burglar Prison warder Karasek s demand-control model of stress development Productive, Motivated Summary of Occupational Stress Any workplace / person / social interaction job control low high low strain passive active high strain Stress is a natural / healthy response Some responses to stress are pathological Worker intolerance Impossible to predict stress reliably easier to predict intolerance Individual modifiers personality, behaviour, coping style, perceptual processes Legal obligation clearer than ever Karasek 1979 low job demands high Risk of psychological strain and increased illness Psychosocial hazards unavoidable & intrinsic in some cases Most psychometric stress testing unethical HUMAN CONDITION, NOT A VARIABLE 31

34 Stress and Immunity Self Directed Activity This material should be completed as part of your own private study and will not be covered in the session. Read either of the following textbooks to help you with this section:- Marieb E. N (2006). Essentials of Human Anatomy and Physiology. 8 th edition. Benjamin/ Cummings. p (Diagram. p314) Marieb E. N (2004). Human Anatomy and Physiology. 6 th edition. Benjamin/ Cummings. p (Diagram. p630) Stress is an important part of survival. When a person feels threatened in some way the fight or flight response is initiated. This allows us to either stand there and fight the threat, or to run away and live to fight another day. There are 2 pathways involved with the stress response. The first part of the body involved is the sympathetic nervous system. These nerves have a rapid response and alone can increase heart rate, breathing rate and blood pressure. However in the stress response the nerves also stimulate the release of the hormone adrenaline from the adrenal gland (which lies just above the kidney) this hormonal response is the second pathway. This allows the stress to have a much longer effect on the body. As nerves have a rapid but short lived effect. Hormones take longer to work as they have to be released into the blood stream and move around the body to reach the organs and have an effect, but once they are working they act for a longer period of time. This short-term stress is beneficial as it gets the body physically ready for action by increasing the oxygen and glucose carried in the blood, allowing the body cells to make more energy. This makes the body better equipped to deal with the stress. However long term stress can be damaging to health as hormones act to increase blood glucose, which can increase the risk of diabetes, and increase blood volume putting the body at risk of high blood pressure. Hormones also suppress the immune system meaning the body is less able to fight infection and is also slower to heal, in general wounds take 24% longer to heal in over stressed patients. So short-term stress is beneficial, but longterm stress can have a physical effect on the body, which can affect our health. By reading the above passage and referring to the diagram in the references Complete the flow chart and answer the questions:- 1. The brain and immune system have been shown to be connected. What are the 2 major pathways discussed which connect them? 2. Which route is thought to have the greatest effect on the immune system? 3. When activated by stress the brain intervenes via a hormonal pathway. Which area of the brain first starts the response to stress? 32

35 STRESS RESPONSE The hypothalamus and pituitary gland are found in the BRAIN Nerves HYPOTHALAMUS Corticotropin releasing hormone CRH ADRENAL GLAND PITUITARY ACTH Adrenocorticotropic hormone ADRENAL GLAND ADRENALINE CORTICOIDS SHORT TERM STRESS RESPONSE LONG TERM STRESS RESPONSE 1. Increases h 1. Increases blood s 2. Increases b 2.Increases blood p 3. Release of g into bloodstream 4. Dilation of b increases oxygen taken into lungs. 5. Blood flow diverted towards organs vital for survival Such as the brain, heart and lungs. Blood is diverted away from less essential functions such as the digestion. 6. Increased m 3. Suppresses the I system Key Short-term control Long-term control 4. What hormone does the pituitary gland secrete? 5. This hormone stimulates the release of other hormones in the long-term stress response. Name one of these hormones and where it is released from? 6. What effect do long term stress hormone have on susceptibility to disease? 7. How much longer does it take for wounds to heal in overstressed carers and why? 33

36 By the end of the session, you should be able to: Session 5: Personal Safety Compare your attitudes towards violence and aggression with those of your peers Identify some relevant legislation that relates to personal safety for nurses Recognise the verbal and non-verbal cues that a potentially aggressive person may exhibit Apply a model of managing aggression to a clinical situation Violence & Personal Safety Questionnaire Please consider the following questions relating to violence and personal safety. Even if you have never worked in clinical practice before, consider an aspect of your previous career, or from your knowledge of nursing, to reflect upon. 1. Have you ever faced violence in the workplace, or at school or college? What happened? How did you feel? 2. What helped when you were subjected to violence? 3. How much do you think we should tolerate violent and aggressive incidents in our work as nurses? 4. List the things that you do when you become angry. Which of these are constructive? Which of these are destructive? Signs that somebody is becoming aggressive Non-verbal signs Closeness When somebody is becoming aggressive, personal space is often invaded. This has the effect of making us feel intimidated, and there may be a tendency for us to react either aggressively, or as a victim, allowing ourselves to be abused. Posture Posture can indicate mood. The posture of an aggressive person may be hunched, with tense shoulders. Fists may be tense or clenched, or hands may be constantly opening and closing. Arms may be slightly bent at the elbow. Facial Expression Facial expressions change dramatically when somebody is becoming aggressive. As people become more tense, so their jaw may tighten, they may frown, and nostrils may flare as they start to breath more heavily. Pupils may become smaller, and eyes narrow. 34

37 Eye Movement The use of eye contact will vary greatly from culture to culture, so we need to be aware that any change in the level of eye contact made could be a sign of aggression. Some people stare more, while others will avoid eye contact all together. Physical Contact Physical contact is rare in British culture. When faced with aggression, sometimes it feels natural to use touch to comfort somebody. This should be used with caution, as it may make somebody feel more angry. By touching somebody, their personal space has been invaded, and they may feel threatened. Touch may also act as a cue for the aggressor to touch back, in less subtle ways! Gestures Some gestures can be quite comforting, whereas others can be provoking. Pointing, or jabbing the finger at somebody is a sign of aggression, as is brandishing the fist. Tapping repeatedly can be quite irritating. Signs that somebody may be becoming aggressive Verbal Indicators Depersonalizing Language Aggressors often use depersonalising language to turn a human being into an objector an anonymous group, thereby making it more justifiable to attack. It may be noticed by phrases like You lot are all the same, or the use of debasing swear words, such as bastard, bitch. Repetitive language As an aggressive situation escalates, so the use of language becomes more repetitive, thus, I m gonna get you, I will; I mean it, I will; I ll get you! are comments which should not be ignored Emotional Content/Incongruity There is often incongruence between what we say and how we say it. This is true in an aggressive situation also. People may talk of being fine when they clearly are not, as the incongruity of the verbal and non-verbal parts of the message can be recognised. Tone/Pitch/Rate/Rhythm Strictly paralinguistic communication, much can be gleaned from the change in pitch and rate and tone of someone s voice. Some people will become very loud, while others may quieten down, or say nothing. The pitch of voice will usually become higher. Rate varies from person to person, some people speaking quickly, while others quite slowly and methodically. The key here is to be familiar with how people have reacted in these situations in the past. Question: Are there any other verbal and non-verbal communication changes that you can think of, which you might notice in an aggressive person? 35

38 Personal Safety Learning Outcomes Supporting Resources By the end of the session, you should be able to: Compare your attitudes towards violence and aggression with those of your peers Identify some relevant legislation that relates to personal safety for nurses Recognise the verbal and non-verbal cues that a potentially aggressive person may exhibit Apply a model of managing aggression to a clinical situation This session is supported by an interactive CD-rom on personal safety. You can access this by going to the lending library or the reference library and borrowing in the usual way. Signs that someone is becoming aggressive The Cycle of Aggression Non-verbal signs and signals Verbal indicators CRISIS Closeness Posture Facial expression Eye movement Physical contact Gestures Depersonalizing language Repetitive language Emotional content Tone, Pitch, Rate Incongruity Level of arousal TRIGGER ESCALATION RECOVERY DEPRESSION Time Maintaining a Safe Environment What can you do to make yourself more safe: In the hospital? Travelling to and from work? In the community? Maintaining a Safe Environment Know your environment Familiarise yourself with the personal alarm system Adhere to lone worker policy Be aware of unsafe areas in the community Park your car in well lit, visible area Have mobile phone on, using single touch dial system Remember the six-stage plan If diffusion is not working, consider the use of hands-on approaches (within personal capabilities) 36

39 Legal issues Duty of Care Criminal Law Act 1967 Health & Safety Act 1974 The management of Health & Safety at Work Regulations 1992 (amended 2004) RIDDOR 1995 Duty of Care In the clinical environment staff are charged with a duty of care to their clients and patients. CARE PLANS are seen as the means by which care is identified in that obviously a far more powerful duty of care exists to those clients/patients who depend on the agency (staff) for their well-being; they may not be able to look after themselves, unable to move without help, unaware of the dangerous consequences of what they might do, prone to self neglect or do dangerous things to themselves or others. 1.4 of the Code of Professional Conduct (2004) states that you have a duty of care to your patients and clients, who are entitled to receive safe and competent care. Criminal Law Act 1967 Criminal Law Act 1967 Section 3 states that a person may use such force as is reasonable in the circumstances in the prevention of a crime The key word is REASONABLE. If employees adhere to the guidelines laid down in policy an organisation will stand by them in any subsequent legal action.if an employee strays from policy/uses any unauthorised or non recommended techniques or excessive force, an organisation is not obliged to offer support. The key issue here is recording your actions documenting your assessment of the situation your assessment of the intent & potential of the individual (the basis upon which you made the decision to ) And documenting your action (showing that what you did was reasonable & within policy guidelines Health & Safety Act 1974 Health & Safety Act 1974 This Act highlights employers responsibilities and employees responsibilities.in this session we are going to concentrate on your responsibilities as employees. Section 7 & 8 of this Act state that employees Should take reasonable care for themselves & others who could be affected by what they do and what they don t do Shall co-operate with the Employer to ensure Health & Safety duties and requirements are complied with Shall not misuse or interfere with anything that is provided for safety purposes Many staff are not aware that a breach of these is more than simply breaking the agency s rules BUT could also constitute a criminal offence. Which is why all the legal issues discussed today stress the importance of care plans/risk assessment & documentation 37

40 The management of Health & Safety at Work Regulations 1992 (amended 2004) RIDDOR 1995 This Regulation also emphasises the importance of RISK ASSESSMENT who is exposed to the risk, in what circumstances & what safety measures need to be put in place. Training, audit & documentation are also highlighted Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (1995) RIDDOR (1995) states that all incidents must be reported. This includes road traffic incidents of the employee whilst out on business of the employer. Demonstrating Non Aggression Your comments If you have any points you would like to raise about this session, please contact us in the following way: 38

41 Section 2: Introduction In this section & subsequent sections, you will follow a case-study to help illustrate the links between physiology and nursing skills and also to highlight branch issues that you may need to consider when caring for individuals. Case Study: Margaret is a 45-year-old woman; she lives with her husband & three children, Keri 17 years, Dan 15 years & Beth 12 years. She has always been fit and well but lately her smoker s cough has become more troublesome. Margaret visits her General Practitioner (GP) complaining that her cough has become more persistent & that she is coughing up thick brown sputum; that appears to have streaks of blood in it. The GP questions Margaret & finds out that she has smoked approximately 20 cigarettes per day for the past 15 years. He notes that she has a pigeon chest and can hear coarse crackles when he listens to her chest. Margaret s observations are BP 140/90, pulse 92 beats per minute, temperature 36.9 o C, respiratory rate 18 breaths per minute The GP orders a chest x-ray (CXR) and some blood tests and refers Margaret to a respiratory consultant for urgent assessment. Margaret is now attending the outpatient clinic (OPA) to see the respiratory consultant with the results of her tests. If Margaret had a learning disability and lived in a residential home her cough and thick brown blood streaked sputum may go on for a while before being noticed by care staff or it may be that Margaret does not tell the care staff. Once noticed, Margaret will need to care staff to make an appointment and take her to see her GP (this is part of their role to support individuals & facilitate access to primary health care). This would be the same if Margaret lived at home with her parents or other family members. If Margaret lived independently & her local Community Learning Disability Team (CLDT) (i.e. for advice on medication or anxiety) knows her and she happens to mention her symptoms to a team member they would encourage her to make an appointment to see her GP or make the appointment on her behalf. They would also offer support Margaret with any appointments. Perceptions of GP s: It may be that at this stage the GP may make a judgement about whether Margaret could go through any treatment based on his/her & the carers perceptions of Margaret s learning disability, her level of understanding & her coping skills. Margaret may be frightened about having a chest X-ray & blood tests. She may refuse to give her consent once she gets there. She may also display challenging behaviour. The care staff or CLDT member could attend the appointments with her to help her understand treatments, side effects and help alleviate anxiety. It is important to note that this will be their own perception of what is being said/offered. The issue of consent needs to be highlighted and also that of decision making. Often in these situations the more severe the individual s learning disability the less that they are involved in conversations & issues about their care. It may be that a desensitisation programme needs to be set up the use of planned visits to meet staff and become familiar with the environment. Photographs and role-play may help Margaret predict what is going to happen and who will be doing what. Margaret may also need help informing her day placement/college/work of what is happening and to ensure that her place is kept open. In this section you will consider communication skills, respiratory physiology, respiratory rate & sputum production, posture and ventilation, cells, genetics and cancer. These will include both physiology and nursing skills. 39

42 (Optional for BSc students) Session 6: Communication INTRODUCTION This chapter is designed as a brief overview of some of the principles of communication. The subject area is vast and well researched, but the focus here is upon simple techniques that the nurse can use to improve his or her communication skills. After some definitions and models of communication, the importance of self- awareness will be outlined. Aspects of verbal, paralinguistic and non-verbal communication skills will be discussed, with emphasis upon how these skills can be used effectively within the nursing environment. Finally, barriers to communication will be reviewed. There are a number of exercises dotted throughout the chapter designed to aid understanding of a particular point. Remember that at work we do not merely communicate with the people we care for; we also discuss issues with colleagues and staff from within the multidisciplinary team. It is hoped that the reader will be able to utilise and adapt these skills to a whole variety of nursing situations that they find themselves in. What is Communication? Some definitions of communication: Communication is the process of sharing information using a set of common rules (Northouse & Northouse, (1998)) The term communication covers just about any interaction with another person. It includes sharing information, ideas and feelings between people. It is a two way process; you perceive the other persons responses and react with your own thoughts and feelings (Glover and Radcliffe, (2000)) Communication involves the transmission of meaning from one person to another, irrespective of method. Thinking broadly, it may involve dance, music, Braille, pictures, telephones, the Internet, and sexual activity! Yet we generally tend to think in terms of speech and language as our prime means of communication. (Gates, (2000)) A Model of Communication There are several models of communication (Shannon & Weaver, (1949), de Shazer, (1985), Hargie et al (1994)). Models of communication transcend all branches of nursing. The central tenet of each model seems to describe the sending and receiving of messages, and the reciprocal and inevitable nature of communication. Sender MESSAGE Receiver FEEDBACK SELF-AWARENESS When the concepts of self-awareness are applied to communication within the nursing profession, they can improve nursing practice and the individual s perception of the care they receive. The nurse has a responsibility to communicate effectively to overcome barriers and encourage understanding, and consequently self-awareness is integral for communication to be effective. 40

43 Self-awareness is not just about answering the question, Who am I?, but also What is the effect of me on this moment, and on other people? (Rawlinson (1990)). French (1983) describes the public or open self, which is Exercise Next time you are in a social situation take on the following aspects of your personality: Be friendly, chatty, warm, extrovert, or Be quiet, introvert, moody, sullen. Notice the different effects that this has on the social group, and think about how this applies to nursing practice. known to anyone, and the private self which is not open to observation by others. The private self can be divided into the self-concept, the actual self and the ideal self. The self-concept comprises all aspects of which we are aware. Our self-concept develops throughout our lives as we receive and analyse information form ourselves and those around us. The actual, or real self is the me that we look at objectively - we know who we really are. This does not always coincide with how others see us. The ideal self is the sort of person we would like to be in a perfect world, the person that we are striving to become. Actual Self Public Self Exercise Consider your actual self, your public self and your ideal self, and develop a list of adjectives that you think describes each of these selves. (How do I describe my real self?) (How do others perceive me?) Ideal Self (What would I like to become? How would I like to be perceived? How we see ourselves and perceive others affects the way we communicate. The way an individual communicates internally affects the way they communicate with others and vice versa (Ellis et al (1995)). Self-awareness involves narrowing the gap between the individual s own perception of self and the perception of others (Rawlinson (1990)). The Johari window, described by Luft, (1970), illustrates the four aspects of the self, as outlined below: The Open self is the aspect of the self that is presented to and observed by others. (e.g. things that you are happy to tell others about) The Blind self is that which is observed by others that we are not ourselves aware of. (e.g. habits, mannerisms.) The Hidden self is the area kept to ourselves and we do not reveal to others. (e.g. secrets) The Unknown self is hidden even from ourselves as well as others. (e.g. Why some of us are tidy, and some of us are untidy.) 41

44 Known to Self Unknown to Self Known to Others open blind Unknown to Others hidden unknown Active reflection, both at a personal level and in terms of clinical practice can serve to increase an individual s self-awareness. THE ROLE OF EMPATHY IN THERAPEUTIC COMMUNICATION Empathy is the ability to understand another person s world accurately as if you were existing within it, so as to make them feel understood (Nelson-Jones, (1986). The demonstration of empathy is central to any form of therapeutic communication, and can be displayed in a number of ways, through what we say, and how we present ourselves non-verbally. Along with warmth and genuineness, empathy was adopted by Carl Rogers as one of the core conditions needed by therapists to help facilitate change in others. Being empathetic helps people to feel that their distress has been understood. (see Rogers, (1951, 1970)) Porritt (1990) gives a good account of the difference between sympathy and empathy. She believes that sympathy is simply feeling sorry for another person s situation or predicament. Sometimes, this feeling can overwhelm nurses, thus making any therapeutic interaction ineffective. Empathy demonstrates an understanding of someone s problem without a feeling of having to fix it for them. It is a non-judgemental acceptance of feelings, which creates an environment in which people feel able to share their experiences. As you will see, many of the methods of communication that are used in the therapeutic setting try to draw out an empathetic attitude. METHODS OF COMMUNICATION Typically, communication can be split into three distinct areas: Verbal Communication Paralinguistic Communication Non-verbal communication Verbal communication Verbal communication refers to the linguistic aspects of communication. A word typically has a denotation (an explicit meaning) and a connotation (an implicit meaning). The meaning of words alters between cultures and generations, which without the support of nonverbal cues may lead to misinterpretation. For example: Bad can mean something that is not good (denotation) or it can be used to mean something is very good as in that dress is bad! (connotation), meaning it looks very good. Heavy could also be used in this context in that something that is described as heavy weighs a lot (denotation) alternatively it could be said that dance is heavy, which would mean the dance is good (connotation). People use some of the following verbal remarks when communicating with individuals. 42

45 Open & Closed questions Closed questions usually elicit a one-word response such as yes or no. They are particularly helpful when trying to gather statistical information about a subject, but are not good at establishing the way one feels. e.g. Have you had a wash today, Mr Smith? Open questions are non-restrictive in terms of the response. They are more useful when trying to ascertain people s feelings about a subject, and allow people to express things in more detail. e.g. How have you been since we last met? The value of open questions is that the questioner makes no assumptions about the person he/she is communicating with. Leading questions Leading questions are those questions that force somebody to give a desired response. In a therapeutic setting these are not an effective means of communicating, as it takes away people s choice, as you can see in the following example: You d like to have your lunch now, wouldn t you? Clarifying For therapeutic communication to be effective, it is important for all parties involved to understand the same message. Sometimes, clarification can be used to establish clear meaning and eradicate any ambiguities. This is particularly important when meanings of words may be misunderstood or misinterpreted. e.g. Now let me see if I ve understood you correctly. Paraphrasing and Reflecting Many experts highlight a distinct difference between paraphrasing and reflecting (Hargie, (1997), Tamparo & Lindh (2000)). Paraphrasing and reflecting both involve the repeating of a message back to the sender to demonstrate that it has been understood. To paraphrase, a message is simply echoed back: e.g. Patient : I m scared about my operation today. Nurse: So you re nervous because you have to go for your operation?. A reflective response conveys some understanding of feeling, and would be accompanied by a change in voice tone, or other non-verbal form of communication which is congruous with the message: e.g. Patient: I m scared about my operation today. Nurse makes eye contact and sits beside the patient. Nurse: You feel nervous because you have to go to theatre. Exercise Watch somebody speaking for a while, say on a TV programme (a political programme is a good example), then close your eyes for a while and continue to listen. Notice how your senses adapt to the way you are receiving a message. Do you understand less, or more of what is being said? 43

46 Paralinguistic Communication The different ways which we moderate our speech can be defined as paralinguistic communication. Intonation, pitch, volume, rhythm, tone of voice, and timing can be considered as paralinguistic forms of communication. Exercise Look at how the meaning of a sentence changes depending on which word is emphasised: Meet me in the bar at eight (not anyone else) Meet me in the bar at eight (not the lounge) Meet me in the bar at eight (not at nine) Furthermore, the pitch of the voice placed upon a sentence alters it s meaning. Say: Meet me in the bar at eight Meet me in the bar at eight Meet me in the bar at eight (angrily) (secretly) (sexily) Williams (2002) considers grunts, ums and ahs as forms of paralinguistic communication, and defines them as conversational oil. These sounds are important during telephone conversations, for example, when the message receiver cannot see your face, and you need to communicate that you are following the thread of the conversation. They act as verbal prompts to encourage the flow of conversation. Other forms of paralinguistic communication include: yawning, coughing, tutting, laughing and groaning Non-verbal communication We use non-verbal communication in conjunction with verbal communication. Non-verbal communication includes the use of gestures, touch, eye contact, body posture and silence. Birdwhistell (1970) estimated that between 65 and 70% of social interactions are perceived nonverbally. Whereas verbal communication is perceived aurally, non-verbal communication is perceived visually. Williams (2002) states that we use non-verbal communication for the following purposes: Information giving Seeking information Expressing emotions Communicating interpersonal attitudes (friendliness, anger) Establishing and maintaining relationships Regulating social interaction Non-verbal communication and culture. The use of non-verbal communication changes within cultures around the world. In Britain s culturally diverse society, this is important to remember. Firstly, our individuals may use different forms of non-verbal communication to tell us something, and secondly our non-verbal responses may not be culturally appropriate to that person. Luckmann (1999) writes, [there is a] fundamental principle that all individuals have cultural traditions that influence their patterns of interaction and communication. 44

47 An Acronym for Improving Cross-cultural Communication (LEARN) Listen with sympathy and understanding to the patient s perception of the problem Explain your perceptions of the problem Acknowledge and discuss the differences and similarities Recommend treatment Negotiate Treatment (from Buckwald et al (1994) Below is a list of the most common types of non-verbal communication, along with how they can be adapted to the clinical situation. Where appropriate, some cultural variations have been included for consideration. Silence The use of silence is a tremendously powerful method of therapeutic communication. Arnold and Boggs (2003) believe that within the nursing environment silence serves a number of purposes. It allows the individual and the nurse time to think about what has just been said. It also serves to validate what has been said a pause before moving on lets the individual know that his or her message has been understood. Sundeen et al (1998) believe that silence non-verbally communicates the nurse s acceptance of the individual. Silence is important for individuals, as sometimes it takes time for people to internalise and understand something (often something quite profound) that they have perhaps only thought about for the first time. The skill for the nurse is first of all to feel comfortable with silence, and secondly to convey to the individual a readiness to continue to receive information when the individual wishes to continue. Gestures Gestures can be used to elaborate a point (illustrators), such as pointing; or used to replace speech (emblems), such as thumbs up. They are also used to express closeness in relationships. Groups of friends will often mirror or copy one anothers gestures. Gestures are used universally, and many gestures are the same around the world. However, many are open to cultural misinterpretation. Exercise Some examples (from Axtell, (1998)): Shaking hands as a greeting. In Western culture, a firm handshake is the expected formal way of greeting somebody. In the Middle East, this would signify aggression, so a gentle handshake is more appropriate. In India, a slight bow with hands in a prayer position is the most common form of greeting, whilst in Japan, a bow is also used, but without the use of hands. Thumbs Up. In Britain, this signifies good luck or well done, but means up yours in Australia. Spend five minutes having a conversation with someone while you sit on your hands. How does this feel? Do you think that you can convey your message as effectively? Touch Touch is the most basic form of communication. It is important for the nurse to show respect for individuals space by not getting very close or touching them without first seeking their permission or at least notifying them first, as feeling crowded or being 45

48 grabbed is most uncomfortable for anyone. In addition, lower your stature by occasionally sitting or bending in individual s presence. This can have a beneficial effect on individuals morale and speaks to individuals in ways that invite their response (Ray, (1997)). The tactile system is the first sensory system to develop and is essential for the development of: - Emotional and social development Learning about the body Motor skills Object recognition Cognitive development and communication. Some individuals experience difficulties with touch because of: Institutionalisation (self care needs are the main priority and lack of activities means that the individual becomes withdrawn and /or engages in self stimulatory behaviours) Negative experiences of touch (abuse, rough handling) Their developmental level Their tactile defensiveness (a condition when heightened sensitivity to tactile input causes the individual to respond with excessive withdrawal to touch and tactile experiences (Hill, (1995)) Ingham (1989) found the use of touch to be one of the main communicating skills in intensive care units with critically ill patients. Eye contact Making eye contact serves two purposes. Firstly, it signifies that you are interested in what somebody is saying, and secondly, you are taking in information visually, picking up on the other s non-verbal communication. Different amounts of eye contact signify different meaning. Too little may signify boredom, whereas too much may be intimidating. In a conversation between two people, research has shown that the person listening makes more eye contact than the person talking (Kleinke, (1986)). As with gestures, eye contact has different meanings in different cultures. For example, in Western culture, a lack of eye contact makes one assume that someone is either disinterested, or shy. Muslim women, however, are taught that it is not permitted to make eye contact with men. We are taught to look directly at somebody when we are being told off. Some cultures see this as a sign of disrespect. Some points to remember: An attentive listener will make regular eye contact to demonstrate that they are taking in what is being said. When information giving in nursing, the nurse s confidence in the information will be more apparent if there is lots of eye contact. In a clinical context, little or no eye contact may be a sign that somebody is feeling low in their mood, so may be showing signs of depression. In an aggressive situation nurses should use eye contact appropriate to the person, their culture and the situation (Morcombe (1999), Vaughan Bowie (1996), Argyle 46

49 (1988)) suggests that prolonged staring at an individual may be interpreted as a signal of attack. Therefore eye contact should be intermittent. Body Posture Body posture can be used to help develop rapport between individuals, and refers to how we position ourselves in relation to others and our environment. As with other forms of nonverbal communication, posture is governed by social norms and conventions. There are situations when an upright, formal posture is needed (such as an interview), and others where it is alright to be more relaxed. From a nursing perspective, posture can be used to convey that the nurse is listening or understanding what somebody is saying. Faulkner, (1992), for example, sees sitting on the edge of a patient s bed as giving a degree of reassurance to the patient, and shows interest and concern. Standing above a patient on the other hand can be quite intimidating. Williams (2002) defines the difference between open and closed body posture. An open posture (relaxed, arms and legs open as opposed to crossed) demonstrates warmth and attentiveness, whereas a closed body posture (arms folded, head drooped) shows disinterest. Facial Expression Universally, according to Ekman (1982), there are seven main facial expressions, which we use to display surprise, fear, sadness, joy, disgust, anger and interest. Facial expressions are used to reinforce the verbal message, or to confirm understanding on the part of the listener. Proximity According to Hall (1966), in Western culture, most interpersonal communication occurs at between 45 centimetres (18 inches), and 120 centimetres (4 feet). Communication that occurs within 45 centimetres is considered to be intimate communication. This has particular relevance to the nurse, and other health professionals, as we often have to invade people s intimate space. Again, space and proximity varies within cultures. In Japan, for example, people prefer a greater distance for interpersonal communication to occur, whereas in Latin American countries, this distance is closer. Exercise Here again is a list of contexts in which we rely on the use of non-verbal communication: Information giving Seeking information Expressing emotions Communicating interpersonal attitudes (friendliness, anger) Establishing and maintaining relationships Regulating social interaction Consider how you would modify your non-verbal communication skills within each of these contexts. INTERPERSONAL SKILLS FOR EFFECTIVE COMMUNICATION Interpersonal communication is a transactional process of exchanging messages and negotiating meaning to convey information and to establish and maintain relationships 47

50 Interpersonal suggests something that is going on between the people involved (usually two people, not always in a face to face situation). Ellis et al (1995) suggests that when reflecting on acts of interpersonal communication there is a requirement to consider the wider social context, the social contexts of sender and receiver of the communication, and the structure of power relationships between those involved. When face-to-face communication involves only two people it is referred to as dyadic communication, the conversation being called a dyad. Listening Listening is what we do when we are receiving the verbal part of a message. It is commonly held that we can listen both actively and passively, but to demonstrate empathy in a therapeutic setting, nurses need to demonstrate active listening. (see Balzer-Riley, (2000)). Active listening uses a combination of non-verbal and paralinguistic skills, and aims to make the speaker feel understood. Egan (1998) developed the following acronym, which highlights the non-verbal skills that can be used to show that you are actively listening or attending to what is being said: Sit square-on Open posture Lean Forward Eye contact Relax Paralinguistically, the use of conversational oil, as outlined above, and in Williams (2002) is another tool for active listening. The use of hmm and uh-huh encourage the flow of conversation. Exercise Ask a friend to describe a recent news item that has interested them. Using the attending skills outlined above, listen to what they are saying. Notice how you use the non-verbal skills. How much eye contact did you make? How close did you sit? Initiating a successful interaction Should this be formal/informal? Think about how this changes with the different people that you come into contact with. Rowe (1999) states that inherent inequalities exist in the nurse patient relationship. The nurse has a degree of power over the patient or individual in that she/he can to some extent: Set the agenda for the healthcare intervention Control the environment Control information. 48

51 The effective use of non-verbal communication Touch, and the gestures we use are important aspects of non-verbal communication (Hargie et al (1994)). There are also some basic principles of communication that nurses should be aware of and must practice if they are to effectively manage aggressive situations. The first is that a person cannot avoid communicating. Even if they remain silent during an aggressive situation, non-verbal clues may have an effect upon the aggressor and may escalate or deescalate the situation. Giving clear explanations When giving explanations, nurses need to ensure that their language is appropriate, avoiding jargon or colloquialisms. Nursing research (Rowe (1999); Morcombe (1999); Morrison & Burnard (1991)) suggests that complaints or disputes escalate if one person misperceives or misunderstands what another person has said or done. Questioning Appropriately The use of open, closed and leading questions as a form of verbal communication was looked at earlier. The skill for the nurse is knowing when to use these appropriately. Closed or direct questions have the disadvantage of making somebody feel interrogated, but do have some value when the nurse is trying to gather demographic data. You may notice such questions at the start of an assessment. Open questions allow the individual much more freedom of expression, and are used to elicit feelings about a particular subject. The use of open questions helps any interaction feel nondirective and non-threatening, and is more congruent with a humanistic, empathetic approach. Tamparo & Lindh (2002) describe how open-ended questions can be turned into indirect statements, to further help the individual to feel that they are not being interrogated and to encourage verbalization of feeling. e.g. How did you feel your operation went? (open question) I d like to hear how your operation went. (indirect statement) Other helpful questioning styles (from Stanton, (1996)): The hypothetical question (or the miracle question, as used in Solution Focused Practice (de Shazer (1985)) is very helpful in therapy to help people to focus upon achievable goals. e.g. If you were to wake up in the morning, and all of your problems had gone away, what would life be like? The probing question is used to try to elicit more detail if more is needed. e.g. You say you feel that no-one likes you at work. Can you give me an example of this? The mirroring question is a useful style of questioning, as its reflective nature helps the individual to feel understood, and is a good demonstration of empathy. e.g. What you re saying is that you started to get these headaches after you lost your job, is that right? 49

52 Being assertive Assertive communication is a valuable skill to be able to use. An assertive nurse is comfortable with his or her feelings, and the feelings of others, and comes across as confident and in control. Porritt (1990) makes the distinction between passive, aggressive, passive-aggressive and assertive styles of communication. We engage in passive communication when we want to avoid hurting people s feelings, but usually at the expense of feeling upset ourselves. It has the impact of making somebody feel guilty, and does not let the other person know how you really feel. We engage in aggressive communication when we feel threatened it is a way of protecting ourselves. It involves a lot of blame towards the other person and makes the other person feel hurt. Passive-aggressive communication can be spotted, as there is often incongruence between the verbal and non-verbal aspects of the message. Undertones of sarcasm or humour are used, and it often makes the other person feel put-down and confused. When communicating assertively, people will maintain ownership of the way they feel, pointing out the effect that other peoples behaviour is having upon them. It helps people to feel accepted and valued, and nurtures an environment of trust. An assertive approach is more likely to be used when working with colleagues than with individuals, and may be effective in the following situations. When you need to tell somebody how you feel about something they have done When you need to ask for something When you want to say no Exercise Consider the following situation: You are approached by a colleague, who has asked to swap shifts with you this weekend. Decide whether the responses are assertive comments, passive comments, passiveaggressive comments or aggressive comments. No, I can t swap shifts with you. You always ask me to swap and it s not fair. You only ask me because you know I will say yes, so I m not going to this time. I felt really upset when you asked me to swap shifts. I feel as though you always ask me and that is making me feel angry towards you. Sorry, I don t think I will be able to swap with you this weekend. Oh, I m really sorry, I can t swap with you because I m going away this weekend, and it s my son s birthday. If you d asked me earlier I may have been able to swap. Please don t feel bad. I may be able to swap but will have to check with my partner that we don t have plans. I will get back to you tomorrow. What, again? I m always swapping with you. I ll do it this time, but you owe me one for this, OK? Yes, I think I can swap shifts this weekend. I was due to go to the pictures, but I can change my plans. Isn t it odd that you always seem to ask me to swap? 50

53 Gabor, (1994) devised the following acronym for assertive communication: Think before you speak Apologize when you blunder Converse, don t compete Time your comments Focus on behaviour, not personality Uncover hidden feelings Listen for feedback OBSTACLES TO EFFECTIVE COMMUNICATION Varcarolis (2000) offers the following techniques to help nurses avoid engaging in ineffective communication: Avoid asking excessive questions. People may feel intimidated if they are asked too many questions, particularly closed questions. Remember that open-ended questions allow for the conversation to flow naturally. Avoid giving advice. Offering advice positions you as an expert in someone else s life, and takes away the decision making process from the individual. Avoid giving false reassurance. Giving false reassurance makes light of the individual s situation and experiences. Avoid asking too many why questions. Too many why questions can be perceived by the interviewee as intrusive and judgmental. It can also lead to defensive answers, and undermine the therapeutic nature of the conversation. Avoid giving approval. In order to give approval, we make a value judgement about somebody s actions. Whilst this may satisfy the need to gain recognition and attention, it sometimes can be misinterpreted. REFERENCES Arnold, E. & Boggs, K.U. (2003) Interpersonal Relationships. Professional Communication Skills for Nurses. Missouri: Elsevier Science. Argyle, M. (1988) The Psychology of Interpersonal Communication. London: Penguin. Axtell, R.E. (1998) Gestures. The Do s and Taboos of Body Language around the World. New York: Wiley. Birdwhistell, R.L. (1970) Kinesics and Movement. Philadelphia: University of Pennsylvania Press. Buckwald, D. Carals, P., Gany, F. et al (1994) Caring for patients in a multicultural society. cited in Balzer-Riley, J.W. (2000) Communication in Nursing (4 th Edition). St. Louis: Mosby. de Shazer, S. (1985) Keys to Solutions in Brief Therapy. London: Norton. Egan, G.E. (1998) The Skilled Helper a Problem-management Approach to Helping (6 th Edition). California: Brooks and Cole. 51

54 Ekman, P. (1982) Emotion in the Human Face (2 nd Edition). Cambridge: Cambridge University Press. Ellis, R.B. et al (1995) Interpersonal communication in nursing. Theory and Practice. Edinburgh: Churchill Livingstone. Faulkner, A. (1992) Effective Interaction with Patients. London: Churchill Livingstone. French, P. (1983) Social Skills for Nursing Practice. London: Chapman and Hall. Gabor, D. (1994) Speaking Your Mind in 101 Difficult Situations. London: Prentice Hall. Gates, B. (2000) Learning Disabilities. London: Churchill Livingstone. Glover, D. & Radcliffe, M. (2000) Communication and lifelong learning. Nursing Times. 96(22) p Hall, E.T. (1966) The Hidden Dimension. New York: Doubleday. Hargie, O., Saunders, C. & Dickson, D. (1994) Social Skills in Interpersonal Communication. (3 rd Edition). London: Routledge. Hargie, O. (ed.) (1997) The Handbook of Communication Skills (2 nd Routledge. Edition). London: Hill, G. (1995) The Multi-sensory Action Pack. Social Education Centre, Stallington Hall, Blithe Bridge, Stoke on Trent, Staffs. ST11 9QU Ingham, A. (1989) A review of the literature revealing touch and its use in intensive care, cited in Haire, J. (1998) Communication and trauma management. Emergency Nurse. 6(5), p Kleinke, C.L. (1986) Gaze and eye-contact: a research review. Psychological Bulletin. 100, p Luckmann, J. (1999) Transcultural Communication in Nursing. New York: Delmar. Luft, J. (1970) Group Processes: An Introduction to Group Dynamics. California: National Press Books. Morcombe, J (1999) Interpersonal approaches to managing violence and aggression. Emergency Nurse. 7(1), p Morrison, P. & Burnard, P. (1991) Caring and Communicating. Basingstoke: MacMillan. Nelson-Jones, R. (1986) Human Relationship Skills. London: Cassell. Northouse, L.L. & Northouse, P.G. (1998) Professionals. Stamford: Appleton and Lange. Health Communication. Strategies for Porritt, L. (1990) Interaction Strategies. An Introduction for Health Professionals. Edinburgh: Churchill Livingstone. Rawlinson, J.W. (1990) Self awareness: conceptual influences, contribution to nursing and approaches to attainment. Nurse education Today. 10(2), p Rogers, C.R. (1951) Individual-centred Therapy. Boston: Houghton Mifflin. 52

55 Rogers, C.R. (1970) On Becoming a Person: A Therapist s View of Psychotherapy. Boston: Houghton Mifflin. Rowe, J (1999) Self-awareness: improving nurse-individual interactions. Nursing Standard. 14(8), p Shannon, C. & Weaver, W. (1949) The Mathematical Theory of Communication. Illinois: University of Illinois Press. Silverman, J., Kurtz, S., & Draper, J. (1998) Skills for Communicating with Patients. Oxfordshire: Radcliffe Medical Press. Stanton, N. (1996) Mastering Communication. (3 rd Edition). Basingstoke: Palgrave. Sundeen, S.J. et al (1998) Nurse-individual Interaction: Implementing the Nursing Process. St. Louis: Mosby. Tamparo, C.T., & Lindh, W.Q. (2000) Therapeutic Communications for Health Professionals. (2 nd Edition) Canada: Delmar. Varcarolis, E.M. (2000) Psychiatric Nursing Clinical Guide. Assessment Tools and Diagnoses. London: Harcourt. Vaughan Bowie (1996) Coping with Violence: A Guide for the Human Service (2 nd Edition). London: Whiting & Birch Ltd. Williams, D. (2002) Communication Skills in Practice. A Practical Guide for Health Professionals. London: Jessica Kingsley. Wilson, Hantz & Hanna (1995) Interpersonal Growth through communication (4 th Edition). WCB Brown & Benchmark publishers. 53

56 Session 7a: The Physiology of Respiration Self-Directed Activity You should complete this work in your own time using the workbook and a web based presentation. This work will introduce key concepts of breathing and respiration that will provide a basis for further discussion in the Respiratory Rate and Sputum and Respiratory function sessions. The physiology of respiration is being delivered using a combination of electronic and printed material. A Web-based, animated Power Point presentation is available from the physiology website - just follow the links from module GM4078 web-page or go direct via You can access the website from any UCE student computer or from your home computer. If you have problems accessing this information there are CD ROMs available for you to use in the library. You can also take these out overnight. The following pages are a résumé of the Physiology of Respiration Power Point presentation. You will need to access the presentation to complete the tasks below. Questions on topics covered in this presentation may appear in the module test. By the end of this lecture you should be able to: Describe the anatomical features of the respiratory system Describe the process of ventilation (how the lungs fill and empty with air) and how ventilation may be altered. Describe the structure of the alveoli and explain how gases (oxygen and carbon dioxide) diffuse between the alveoli and the blood. Explain how breathing rate is controlled. Why do we need to breathe? Breathing gets oxygen into the body so that cells can make energy. Cells use this energy to contract muscles and power the thousands of biochemical reactions that take place in the cell every second. Without oxygen, cells can t make energy and without energy, cells would die Energy production Inside the cells, most energy is made by the mitochondria. This energy is in the form of a small packet of energy called ATP (adenosine triphosphate). Complete the gaps in the following statement: Task 01 - In the process of energy production (gas) is consumed by the cells (gas) is produced as a waste gas (sugar) fuels the process How do cells get their oxygen? Oxygen (O2) from the air in the lungs diffuses into the blood. It is transported in the blood to the cells. Oxygen diffuses from the blood into the cells. 54

57 How do cells dispose of their carbon dioxide? Carbon dioxide (CO2) from the cells diffuses into the blood, It is transported in the blood to the lungs. In the lungs carbon dioxide diffuses into the air and is breathed out Gas A Gas B Task 02 - Label the key to the diagram on the right. Which gas is oxygen and which is carbon dioxide - A or B? The anatomy of the Respiratory System Gas A Gas B = = Task 03 - Label this Diagram of the Respiratory system Roger McFadden University of Central England

58 The anatomy of the Respiratory System alveoli The respiratory system consists of a series of tubes that transfer air from the outside to the alveoli at the end of the smallest of bronchioles. This is where gas exchange takes place. There are millions of alveoli in each lung, each surrounded by a network of small blood vessels called capillaries terminal bronchiole capillaries Gas exchange in the alveoli exchange takes place between the alveoli to the blood in the capillaries Task 04 - Label the key to the diagram on the right. Gas A diffuses from the alveoli to capillaries. Gas B diffuses from the capillaries to the alveoli. Which gas is oxygen and which is carbon dioxide? A B Gas A Gas B What is diffusion? Diffusion is a process that occurs when there is a difference in the concentration of a substance between two areas. The substance, for example oxygen, will diffuse from an area of high concentration to an area of low concentration. No energy is required from the body for this process 56

59 Ventilation (breathing) Breathing air in and out of the lungs As the ribs rise and fall and the diaphragm domes and flattens, the volume and pressure in the lungs changes. It is the changes in pressure that cause air to enter and leave the lungs ribs AIR Inspiration Ribs rise and diaphragm flattens Volume increases and pressure decreases Air enters the lungs diphragm Task 05 - complete this statement on expiration Expiration Ribs and diaphragm Volume and pressure Air leaves the lungs Control of Respiration Task 06 - fill in the gaps in this statement about the respiratory response to exercise As we exercise, the body needs to obtain (more / less) oxygen and remove (more / less) carbon dioxide. This is done by (decreasing / increasing) the rate and depth of breathing. A (decrease / increase) in levels of (oxygen / carbon dioxide) in the blood during exercise is the main trigger that (decreases / increases) the rate and depth of breathing. Chemoreceptors in the respiratory centre in the brain stem s medulla detect an (increase / decrease) in blood (O2 / CO2) levels. The intercostal and phrenic nerves (decrease /increase) the rate and depth of breathing. Additional chemoreceptors on arteries near the heart monitor (nitrogen / oxygen) and blood acidity 57

60 Control of Respiration brain chemoreceptors on aorta and carotid artery respiratory centres in medulla heart phrenic nerve to diaphragm intercostal nerve to external intercostal muscles ribs diaphragm Response to Hypercapnia Diseases such as emphysema, bronchitis and asthma can impede the movement of gas between the alveoli and the blood. CO2 levels can build up in the blood known as hypercapnia. This stimulates the chemoreceptors in the respiratory centre of the brain and the rate and depth of breathing increase to expire more CO2 and reduce levels in the blood. Task 07 - Bronchitis can cause excess mucus to form in the lungs and sufferers can find it difficult to breath out. Air becomes trapped in the lungs. Explain in terms of diffusion why should this lead to carbon dioxide retention 58

61 Session 7: Respiratory Rate & Sputum Margaret presented at her GPs with a productive cough and increased respiratory rate. This session explores how these would be assessed by a nurse and their physiological significance. Brief outline of the skill Respiratory rate is another important vital sign providing information about the health of the patient/client. Respiratory observations are carried out to establish a baseline, to monitor for any fluctuations and to evaluate the response to medications or treatments that affect the respiratory system (Mallett & Dougherty, 2000; Torrance, 1997). However, it is not clear exactly when or how often they should be recorded (Torrance, 1997). Measuring the respiratory rate only provides information relating to the mechanics of breathing; it is only a small part of the assessment of respiratory function, i.e. the effectiveness of respiration in supplying oxygen to the cells and removing carbon dioxide (Torrance, 1997). One respiration consists of one inspiration, one expiration and a brief pause (Blows, 2001). Normal relaxed breathing is effortless, automatic, regular and almost silent (Mallett & Dougherty, 2000). How to carry out the Skill 1. The patient/client should rest for at least five minutes prior to measuring the respiratory rate (Torrance, 1997). 2. There are four characteristics that need to be noted when measuring the respiratory rate: Rate the respiratory rate is the number of respirations that occur in one minute (Jamieson et al, 2002). Rhythm the respiratory rhythm is normally regular however, it is common for infants to have an irregular breathing pattern with alternating short periods of apnoea (no breathing) and rapid breathing (Baillie et al, 2001) Depth the depth of respirations is assessed by observing the degree of movement in the abdominal wall in children under the age of 7 years and in the chest wall in older children and adults (Hazinski, 1999). The chest should also be observed to ensure that it expands equally on both sides, especially if there is a history of chest injury (Baillie, et al, 2001). Sound normal respirations make very little sound. If wheezing or a stridor (a harsh sound heard on inspiration) is heard this may indicate respiratory disease or obstruction. 3. When measuring the respiratory rate the colour of the individual should also be assessed. Healthy skin is warm and well perfused, the mucous membranes and the nail beds are pink in colour. However, changes in the colour of the mucous membranes and nail beds will occur if oxygenation of the tissues is low or unusually high. The lips, mouth and nail beds should be checked for signs of cyanosis (bluish tinge). If present, this should be recorded and reported immediately. 59

62 ACTIVITY: Please answer the following questions in your groups: 1. Why should you not seek consent from the patient/client prior to measuring the respiratory rate? 2. Why is it recommended that you rest the person s hand on their abdomen when measuring respiratory rate? 3. What is the acceptable range for respiratory rate for (a) an adult (c) child approx six years old (b) an adolescent (d) Newborn 4. Why is it important to measure the respiratory rate for one full minute? (a) In adults: (b) In babies: 5. What do you understand by the following terms relating to respiratory rate measurement? Dyspnoea Bradypnoea Tachypnoea Apnoea Orthopnea Cheyne-Stokes respiration. Stridor Wheeze Stertorous respirations Rales and crepitations Cyanosis 6. What are the signs of increased respiratory effort following exercise or as a result of respiratory disease? 7. If a person is experiencing difficulty breathing, what position would facilitate maximum lung capacity? 8. When assessing sputum, what might lead you to suspect An infection Pulmonary oedema (fluid in the lungs) 9. What action should be taken if a patient/client is experiencing difficulty expectorating sputum? 10. To which laboratory would a sputum specimen be sent for analysis if an infection is suspected? 60

63 Respiration Rate and Sputum Respiratory Rate The respiratory rate is the number of breaths per minute It can be altered according to the demands of the body Airway Resistance Under normal, healthy circumstances resistance to airflow is low. Airflow through the respiratory system occurs without difficulty. For example: - it may increase during periods of exercise or stress - or decrease during sleep or relaxation. Wide lumen, Low resistance Narrow lumen, High resistance 2 3 This allows oxygen and carbon dioxide to move easily through the respiratory system: - oxygen to alveoli and across into pulmonary circulation to be delivered to cells - carbon dioxide from pulmonary circulation across into alveoli and out of the lungs With certain respiratory conditions, the airway passages are narrowed increasing resistance. This affects the airflow into and out of the lungs. The following conditions increase airway resistance: - Brochitis -Asthma -Tumours Do you think Emphysema increases airway resistance? 4 5 Tumour in the Respiratory System Lung tumour note how it compresses some of the airways 6 Case Studies Michael is 11 years old and has recently developed asthma that is triggered by dust and animal hairs. Recently he went to a friends house not realising that they had a dog. He had an asthma attack and his breathing became difficult, noisy, rapid and shallow. His inhaler rapidly restored his breathing to normal. Explain the physiological changes behind the changes in bold. What did his inhaler do to help? When Margaret was initially assessed by a nurse her breathing rate was about 20 breaths per minute and was coughing up blood streaked sputum. She was finding breathing tiring and was using accessory muscles. Explain the physiological changes behind these observations. 7 61

64 Sputum Test Why the test is performed The cultures and tests are done on the sputum to help identify the bacteria that are causing an infection in the lungs or the airways (bronchi). Normal Values No presence of disease-causing organisms in the sputum is normal. What abnormal results mean The abnormal results will be reported as a positive culture. That means that there is a disease-producing organism found that may help diagnose bronchitis, tuberculosis, a lung abscess, or pneumonia. Sputum consists of: Respiratory tract secretions Nasopharyngeal and oropharyngeal material (saliva) Microorganisms Cells 8 Mucus Mucus secretion and clearance are very important for airway integrity and pulmonary defence. Mucus hyper-secretion and impaired clearance can result in: - abnormal respiratory secretions - impair pulmonary function - reduce lung defenses - increase risk of infection Airway mucus is a visco-elastic gel Protects epithelium from foreign material and fluid loss Secreted by mucus cells (goblet cells of airway surface epithelium and submucosal glands). Estimated mucus secretion volume is between around 100ml per day in a healthy, non-smoking individual Mucus transported via 2 means: - air flow (cough) - mucociliary clearance (see diags) Flows at regular pace up the airways from lower respiratory tract, through the larynx, into the pharynx and is swallowed. Takes minutes for mucus to be cleared from large bronchi Smoking The irritants in the smoke: - inhibit the action of cilia - cause bronchoconstriction - stimulate secretion of mucus Contributes to recurrent infections: e.g. bronchitis - wheezing from increased airway resistance - cough from accumulation of mucus May take several days to clear from respiratory bronchioles 12 Air pollutants, local and general anaesthetics, bacterial and viral infections also reduce mucociliary clearance 13 62

65 Normal operation of cilia Hypersecretion and cough clearance References and Further reading Baillie L, Corben V & Higham S (2001) Respiratory care: assessment and interventions. In: Baillie L (Ed) Developing Practical Nursing Skills, Arnold Publishers, London Blows W T (2001) The Biological Basis of Nursing: Clinical Observations. Routledge, London Hazinski M F (1999) Manual of Nursing Care of the Critically Ill Child. Mosby, London Hull D & Johnstone D (1999) Essential Paediatrics, 4 th Ed. Churchill Livingstone, Edinburgh. Jamieson E M, McColl J M, Whyte L A (2002) Clinical Nursing Practices, 4 th Ed. Churchill Livingstone, Edinburgh. Mallett J & Dougherty L (Ed) (2000) The Royal Marsden NHS Trust Manual of Clinical Nursing Procedures, 5 th Edition. Blackwell Science, Oxford. Sadik R & Elliott D (2002) Respiration and Circulation In: Hogston R & Simpson P M (ed) Foundations for Nursing Practice, 2 nd Edition. MacMillan Press, London pg Torrance C & Elley K (1997) Respiration technique and observation 1. Nursing Times 93 (43). Torrance C & Elley K (1997) Respiration technique and observation 2. Nursing Times Session 8: Psychology Communication and Culture MATERIALS WILL BE PROVIDED IN THIS SESSION 63

66 Session 9: Respiratory Function The effort required in breathing For a normal, healthy individual, breathing at rest requires very little energy. As soon as we have to breathe harder (usually because our oxygen demands have increased), the muscles involved in ventilation are required to work harder. This immediately increases our effort and our energy requirement. To understand which muscles are involved in the different phases of breathing, read the paragraph below. Muscles used in breathing 1. Normal Quiet Inspiration (at rest) Diaphragm During inspiration, the diaphragm contracts and flattens, increasing the lung volume. External Intercostals On contraction these muscles lift the rib cage upwards and outwards. 2. Normal Quiet expiration (at rest) Expiration is a passive process that does not require energy. The muscles that contracted during inspiration simply relax. Through elastic recoil (as if you were to let go of an elastic band), the ribcage is allowed to move back down to its original position. 3. Forced Inspiration The same muscles are used as during normal quiet breathing plus the Accessory Inspiration muscles raise the sternum and first two ribs, enlarging the upper chest. 4. Forced expiration Internal Intercostals During forced expiration, the internal intercostals depress the rib cage. Abdominals will force the diaphragm back to its resting position more rapidly in forced expiration. Two main factors can influence the amount of effort that is required to breathe and therefore the amount of energy required. These are lung compliance and airway resistance. Lung Compliance Imagine trying to blow up a new balloon. Initially a balloon resists your efforts. Compliance relates to the amount of effort required to stretch or distend the lungs. Put another way, compliance is the ability of a substance to yield elastically to a force- in this case it is the ease with which a balloon can be inflated. So a new balloon has a LOW level of compliance, whereas a balloon that has been inflated many times has HIGH / LOW compliance. Alveoli that inflate easily have HIGH / LOW compliance. The presence of a coating called surfactant, lines the inside of the alveoli and prevents the alveolar walls from sticking together during ventilation. Surfactant is important in INCREASING / DECREASING compliance. Surfactant is produced particularly during the final weeks of pregnancy. A premature baby may therefore lack adequate surfactant. This disorder is known as infant respiratory distress syndrome. Can you anticipate the problems that this infant may encounter? Airway Resistance As we inhale and exhale, the air experiences resistance as it travels through our network of airways. This is called airway resistance. Normally, this is minimal and does not cause breathing difficulties - our airways are wide enough not to impede the flow of air. Airway resistance is also kept to a minimum due to the pressure / volume changes that normally occur through the phases or respiration. We now need to review the pressure / volume changes that occur during breathing. Answer the following questions 1. Air flows from a) High pressure to low pressure b) Low pressure to high pressure 2. When volume increases pressure INCREASES / DECREASES 64

67 Thinking about the answers to these questions, we can try to understand what effect this has on our airways. Airway diameter INHALE EXHALE When we inhale, the fall in pressure allows our airways to open up slightly, the airway diameter increases, reducing airway resistance. When we exhale, the rise in pressure compresses our airways slightly; the airway diameter is reduced, increasing airway resistance. If our airways are healthy, this increase in airway resistance does not cause a problem. However, if our airways have a smaller diameter than normal, airway resistance will be increased further, requiring greater effort to breathe. Airway resistance is increased when the diameter of the airway is reduced. 3. List as many factors as you can that would reduce airway diameter and increase airway resistance, making breathing more difficult. The strength of our respiratory muscles, lung compliance and airway resistance will all influence our lung function. To assess lung function we can measure the volume and rate at which we breathe. A spirometer is a machine that measures the volume of air breathed in and out. The trace on the next page shows a standard spirogram reading with definitions of different lung capacities. Measurement of the lung s various volumes and capacities can provide a useful tool in diagnosing and monitoring respiratory disease states. 65

68 Study the spirogram then answer the following questions: 1. Match the lung volumes and capacities with the descriptions given below. VC. Vital capacity TLC. Total lung capacity TV. Tidal volume RV Residual volume a. The amount of air taken in with each inspiration during normal breathing b. Even after maximal expiration some air still remains in the lungs, which can not voluntarily be removed c. The volume of air that represents a person s maximum breathing ability is called. d. Adding RV to VC gives. 2. Would vital capacity be increased, decreased or unaffected if a patient has: a. Weakness of respiratory muscles b. A rigid chest wall (poor compliance) For each case explain the reasoning behind your answer. 3. A person with any of the conditions mentioned in Q2 may tire very easily. Can you think of any reasons why this is the case? 4. Now you have reviewed how ventilation occurs consider how posture could affect the mechanics of breathing. If a patient were having difficulties in breathing would she be better lying down or sat up? Give reasons for your answer. A type of spirometer called a vitalograph is often used on wards, as it is portable and easy to calibrate. Your group will be given a chance to assess lung function in this tutorial. To measure the Forced Vital Capacity (FVC), the patient is asked to inhale as deeply as possible then exhale as forcefully as possible into the vitalograph. The vitalograph will measure the volume of air exhaled in Litres. We can also calculate FEV 1 (Forced expiratory volume in one second). FEV 1 = Volume of air exhaled in one second x 100 FVC This tells you how much of the FVC is exhaled in the first second and can indicate airway obstruction. The FEV 1 should be >70% in a normal healthy person. 66

69 Respiratory volumes* as displayed by a spirometer *volumes shown are those of a typical adult male Volume of air in lungs (litres) TV IC VC TLC RV Time TV Tidal volume 0.5L IC Inspiratory capacity 3.0L VC Vital capacity 4.5L RV Residual volume 1.2L TLC Total lung capacity 5.7L 67

70 Case Study Margaret s daughter Beth has asthma. Asthma is an obstructive lung disease, otherwise known as COAD (chronic obstructive airway disease) or COPD (chronic obstructive pulmonary disease). We have learnt that airway obstruction increases airway resistance, creating breathing difficulties. The airway obstruction is caused by chronic inflammation and swelling of the airways, excessive mucus secretion and muscle spasms (bronchoconstriction). Beth s asthma is not severe but she is required to take medication to help manage her condition. Beth has been prescribed Salbutamol, a bronchodilator which she takes once daily or when required. Since starting the summer holidays, Beth has been forgetting to take her medication and she has become breathless and wheezy. Answer the following questions: 1. Look at the Vitalograph Trace No.1 below obtained several weeks prior to Beth experiencing a worsening in her asthma. a. What is Beth s Vital Capacity? b. Calculate Beth s FEV 1 from Trace 1. c. Is Beth s FEV 1 acceptable? Explain why. 2. Explain, with reference to airway resistance why Beth is wheezing 3. What effect does Salbutamol have on a. Airway diameter? b. Airway resistance? 4. Beth has her lung function assessed again see Trace No. 2 a. State 2 differences between Trace 1 and Trace 2 b. What is Beth s FVC in Trace No. 2? c. Calculate Beth s FEV 1. d. Explain why the FEV 1 in trace 2 is different to trace 1 68

71 BETH 05/06/05 Vitalograph Trace No. 1 BETH 02/08/05 Vitalograph Trace No. 2 69

72 Session 10: Cells, Genetics and Cancer. Margaret has been diagnosed with primary lung cancer. She wants to find out more about cancer and its causes. Self Directed Activity Before coming to this tutorial label the following structures on the diagram below: Nucleus Chromosomes Mitochondria Ribosomes Endoplasmic reticulum Plasma membrane Cytoplasm Using the information you have been given get into small groups and spend a few minutes discussing the following: 1.Why does smoking increase the risk of developing lung cancer. 2. Margaret s cancer is a primary cancer but some cancers are secondary cancers, what is the difference between a primary and secondary cancer/ Why are the lungs a common site for secondary cancers? At the end of this session you should be aware that: 1.The body is made of cells which are constantly being replaced by controlled cell division. 2.Cancer occurs when chromosomes are damaged and division becomes uncontrolled. 3.Most cancers occur due to environmental factors. In a very small proportion of cases inherited factors may increase cancer risk 4.A healthy lifestyle significantly reduces the risk of cancer and other serious conditions. If you would like more information on the topics covered in this session you might like to check out the following websites

73 Cells and Cancer What is Cancer? A collective term for over a hundred diseases. Common feature loss of control of cell division Schematic diagram of typical animal cell 1. Nucleus 3. Mitochondria 2. Chromosome 5. Ribosomes 7. Endoplasmic reticulum 6. Cytoplasm Cells At least several hundred different cell types in an adult with 100trillion cells., Ovuum 300um visible with unaided eye Red blood cell 7.5 um Electron microscope. 4. Cell membrane 71

74 The Development of Cancer Cell Growth Exact replication of cells essential. Cell cycle Normal cell division - mitosis Cancer Abnormal cell division 72

75 Mutations in DNA central to these changes in growth patterns. What is a mutation? Change in DNA Change in protein structure and maybe function. Causes of Cancer Cancer arises from mutations in DNA Environment cigarette smoke chemicals UV light viruses DNA Metabolic processes free radicals DNA copying and repair defects Inherited genetic mutations Between 3 7 mutations in a cell are required to make it cancerous Steps in the metastasis of an epithelial cancer basement membrane Metastatic Spread Loss of adhesion to other cells Transport in blood or Lymph Deposit at another site in the body Metastatic subclone Adhesion and invasion of basement membrane Passage through extracellular matrix Entry into blood or lymph vessels Tumour travels in blood or lymph extracellular matrix endothelium basement membrane basement membrane Extravasation Metastatic tumour blood or lymph vessel 73

76 What are the causes of cancer? Margaret has heard that cancer can sometimes run in families. She is worried that it might run in her family and her children may be at increased risk of developing cancer in later life. The diagram shows Margaret s family tree. Stan, d. heart disease Lou, 92 Liz, 80 Joe Vera, 73 Tony, 71 Pam, 67 Alan, 65 Tom, 47 Margaret, 45 Mike, 42 Keri, 17 Dan, 15 Beth, Name Margaret s husband. 2. How many children does Margaret have? 3. Name Margaret s maternal grandmother. 4. Joe died of bowel cancer when he was 77. What relation was Joe to Margaret? 5. Pam was diagnosed with breast cancer at age 65. What is the relationship between Pam and Margaret? 6. Mike and his partner Mary have one son, Zak who is 20. Add Mary and Zak onto the family tree. 74

77 Inherited Cancer Risk. Cancer can be sporadic or inherited. A sporadic cancer is one that does not run in families. It occurs largely due to environmental factors such as diet, smoking, exposure to radiation, drugs etc. Most cancers are sporadic and cannot be passed on to children. Sporadic cancers tend to occur in older age. Inherited cancers are rare. In adults a small proportion of cancers of the breast, ovary and colon/rectum may be partly due to the patient inheriting an increased risk. In infants, inheriting faulty genes may sometimes cause cancer of the retina or kidney. Inherited cancers usually occur at a younger age and the same type of cancer may be seen in several family members. Patients who have a family history of cancer, especially breast cancer, ovarian cancer or colorectal cancer can be referred to the West Midlands Family Cancer Strategy (WMFCS). They have produced a Quick Guide to Inherited Cancers (WMFCS 2003) 1. Between 5 10% of common solid tumours (for example breast, colon or colorectal) are inherited in 3 people in the general population will develop cancer and therefore most cases will be sporadic. In inherited cancer there may be: 3. A high frequency of the same tumour in the family and/or 4. Early age of onset of cancer. 5. Multiple primary tumours in an individual (such as bilateral breast cancer or several colorectal tumours) 6. Recognized rare tumour associations such as Breast and ovary Breast and sarcoma Colorectal, uterus, ovary, stomach. If several of theses features are absent then it is likely that the cancer isn t inherited. Do you think that increased risk of cancer runs in Margaret s family? Give at least 3 reasons to support your answer. Where could you refer a family who may have an inherited increased cancer risk? Reference WMFCS (2003) A Quick Guide to Inherited Cancers Available online at 75

78 Smoking and Cancer (adapted from McCance and Huether (2002) Pathophysiology: the Biologic basis for disease in adults and Children. Mosby) Both epidemiologic and experimental data support the conclusion that cigarette smoking is carcinogenic and remains the most important cause of cancer. Cigarette smoking increases the incidence of cancer of the lung, bladder, pancreas, and, to a lesser extent, kidney, larynx, oral cavity and oesophagus. In fact smoking is the main cause of lung and mouth cancers and accounts for half of the bladder and kidney growths (Fig. 1) (King, 2000). These correlations are not surprising, considering the chemical composition of cigarette smoke. Cigarette smoke includes about 40 different carcinogens that can cause cancers (King 2000). These chemicals possess mutagenic capabilities, and are absorbed from the lungs into the blood, gain access to distant organs through their distribution by the circulation, and are present in increased concentration in the urine of smokers. The greatest risk of lung cancer is related to the inhalation of tobacco smoke, and risk increases with the number of cigarettes smoked. Low tar cigarettes do not reduce the risk of lung cancer. Non- smokers living with smokers, especially children, are also at increased risk of lung cancer due to passive smoking. Figure 1. Increased risks of cancers due to smoking (King 2000) Relative risk Cancer smoker/non-smoker Lung Mouth Bladder 3 47 Kidney 3 48 Reference King R (2000) Cancer Biology. Prentice-Hall. Risk attributable to smoking (%) Questions 1. What is a carcinogen? 2. What is a mutagen? 3. Suggest how carcinogens may affect cells to increase cancer risk? 4. Suggest why alveolar cells are at risk of damage from cigarette smoke? 5. Suggest how chemicals in cigarette smoke may damage cells of the kidney and bladder? 6. What happens to tar that is inhaled into the lungs during smoking? 7. If Margaret s children do smoke, by how much will they increase their relative risk of contracting lung cancer in later life? 8. How much of the risk of bladder cancer is attributable to factors other than smoking? 9. Is it worth Margaret trying to give up smoking now? 76

79 Section 3: Introduction Following her diagnosis of lung cancer Margaret is admitted to hospital the following week for intensive chemotherapy. Margaret is admitted to the oncology ward and needs her baseline observations taken before she commences her treatment. If Margaret had a learning disability she may need help in completing the admission process. It may be that her communication profile (how she communicates, how you know she is happy/sad/in pain, level of understanding etc) will be shared with ward staff. Desensitisation programmes may be introduced if necessary. For example if Margaret appears frightened of having her blood pressure taken she will be shown what will happen through role-play or being shown the equipment and talking about the procedure prompted by the use of photographs. If Margaret has no family and lives independently, a member of the CLDT will visit her in hospital. In this section you will consider the principles of cardiovascular function through the circulatory lead lecture, blood pressure and pulse tutorial. These will include both physiology and nursing skills. 77

80 Session 11: Circulatory Physiology Lecture CIRCULATORY PHYSIOLOGY Introduction Earlier in this module you were introduced to the concept of homeostasis, maintaining a constant internal environment, a steady state. The functions of the circulatory system are vital for homeostasis, as blood flows through the body tissues, nutrients and oxygen move into interstitial fluid and then into the cells. At the same point blood picks up waste products, carbon dioxide and heat. This continuous circulation of the blood around the body is driven by the pumping action of the heart. As maintaining an adequate circulation is vital to health, many of a nurses observations are concerned with assessing the state of an individuals circulatory system. In your skills session you will be introduced to pulse rate and measuring blood pressure and the information these observations can provide as to circulatory function. On the following pages you will find several diagrams that will accompany your lecture notes and tutorial on the circulatory system. It is important to study the following sheets and complete any questions or pre-reading before coming to your first session. 78

81 Circulatory System Physiology At the end of these sessions you should be able to; Describe the normal structure and functions of the circulatory system Explain how blood flows through the heart Name the components of the hearts conduction system Heart Structure Before we start how much do you already know? You should have attempted to label the diagram of the heart before the session. What blood vessels supply the heart itself with blood? What components make up the cardiovascular system? Cardiovascular system cardio - refers to heart vascular - refers to blood vessels Is composed of the following organs 1. Heart: continually pumps blood from an area of high pressure to an area of low pressure 2. Blood vessels: hollow passageways through which blood is directed and distributed to the body s tissues and back to the heart again 3. Blood: transport medium within which materials being transported are dissolved or suspended Functions of the circulatory system Every cell in your body needs oxygen in order to live and function. The role of the heart is to deliver the oxygen-rich blood to every cell in the body. The arteries are the passageways through which the blood is delivered. The largest artery is the aorta, which branches off the heart and then divides into many smaller arteries. The veins carry the deoxygenated blood back to the lungs to pick up more oxygen, and then back to the heart once again. Functions of the circulatory system continued. Blood flows continuously through the circulatory system, and the heart muscle is the pump which makes it all possible! To transport blood to all cells This allows the delivery of: - Oxygen and glucose for cellular respiration - Nutrients; vitamins and minerals for cell functions - Hormones; for cell actions This also allows for the removal of: -Metabolic wastes such as carbon dioxide and urea which can cause toxicity and lead to cell death The Heart Wall The heart wall is composed of 3 layers: Epicardium (outer layer) The visceral layer of the serous pericardium. Myocardium (middle layer) Thickest layer of the heart wall. Composed mainly of cardiac muscle tissue with some connective tissue. Responsible for the contraction of the heart. Endocardium (inner layer) Thin layer of epithelial cells that line the chambers of the heart and the heart valves. 79

82 Compare the 2 sides of the heart RIGHT SIDE LEFT SIDE Pulmonary and Systemic Circulation:Double pump system See:- Schematic Diagram of Circulatory System Pulmonary circuit Deoxygenated blood returns from the body to the right atrium. It is then pumped to the right ventricle and from here the blood is sent via the pulmonary artery to the lungs. At the lungs the blood picks up oxygen and removes carbon dioxide. Systemic circuit Oxygenated blood returns to the left atrium. It is pumped to the left ventricle and from here the blood is sent via the aorta to the rest of the body. At the cells the blood delivers oxygen and nutrients required for respiration. The heart is a Double pump sending blood to the heart and lungs simultaneously What is the Pulse The pulse can be felt when the artery lies close to the surface and can be compressed against firm tissue such as bone e.g Radial pulse The difference between systolic and diastolic pressure is the pulse pressure or mean arterial pressure. What is systolic/ systole? What is diastolic/diastole? What are the Lub, Dub noises of the heart heard through the stethoscope? Electrical Activity and the Heart Recorded via an electrocardiogram (ECG) - Living cardiac muscle tissue conducts electricity - Electrical stimulation passing through the cardiac muscle tissue causes it to contract - Electrical stimulation follows a set path through a healthy heart - This produces a coordinated heart beat. Control of heart rate Heart rate is controlled by 2 separate systems Intrinsic control:- Autorhythmic (pacemaker cells) Conduction system Extrinsic control:- Nerves (autonomic) Hormones How is the Electrical Stimulation Produced In a Healthy Heart Intrinsic control - By the Sinoatrial node (SAN) - This acts as a natural pacemaker - Located in the posterior wall of the right atrium - SAN is self excitatory - On excitation the SAN produces an electrical charge HR = excitation rate of SAN 80

83 Intrinsic Control:- Specialised conduction system of the heart Sinoatrial (SA) node Right atrium Right branch of Bundle of His Right Ventricle Atrioventricular (AV) node Left atrium Left branch of Bundle of His Left Ventricle Purkinje fibers Conduction through the heart 1. By cardiac muscle tissue - Muscle cells form a functional syncitium 2. By specialised structures - Atrioventricular node - Bundle of His (aka AV Bundle) - Purkinje fibres Spread of Cardiac Excitation AV Node: - carries electricity from the atria to the ventricles through the AV valves - the connective tissue of the AV valves do not conduct electricity - AV valves separate the atria from the ventricles except for the area of the AV node AV Bundle: - carries electricity - flow of electricity down towards the apex of the heart Spread of Cardiac Excitation Purkinje Fibres: - distributes electricity to the ventricles from the apex UPWARDS - thus the ventricles contract from their base upwards - this improves the pumping efficiency of the ventricles - since blood is lifted upwards towards the aorta and pulmonary artery. See reference:- Marieb (2004) chapter 18. The cardiovascular system: The heart. Diagram 18.14:- The sequence of excitation of the heart related to the deflection of an ECG tracing.p694 Spread of Cardiac Excitation Right atrium Left atrium Sinoatrial Node Atrioventricular Node Bundle of His Purkinje fibres Extrinsic Control The chemoreceptors monitor the levels of chemicals e.g CO 2 in the blood and adjust the heart rate accordingly. See diagram: - Control of the heart by the sympathetic and parasympathetic systems The autonomic nervous system modifies the beat:- 1. Which division increases heart rate 2. Which division decreases heart rate Right Ventricle Left Ventricle These autonomic nerves modify the heart rate to meet the demands of the body 81

84 Anterior view of the heart in vertical section Label this diagram before your first lecture Can you draw in the components relating to the electrical conductivity of the heart? Check your answers on the Physiology web site 82

85 Schematic Diagram of Circulatory System lungs pulmonary arteries right atrium left atrium pulmonary veins aorta right ventricle left ventricle heart vena cava venous return from organs and tissue beds arterial supply to organs and tissue beds 83

86 Control of the heart by the sympathetic and parasympathetic systems parasympathetic efferent neuron heart sympathetic efferent neurons adrenal gland kidney Neurotransmitters of the sympathetic and parasympathetic systems parasympathetic system sympathetic system acetylcholine noradrenaline heart 84

87 Session 12: Heart Rate and Blood Pressure Useful Link: UCE MOODLE It is essential that you read the material on blood pressure on the Physiology web site BEFORE coming to the circulatory tutorial session. The blood pressure material can be found on the Physiology page of the School of Health and Policy Studies web site, and is accessed through the BASICS link. Direct link: Case study one Margaret collapses and cuts her leg causing mild blood loss. The nurse takes her pulse (tachycardic) and blood pressure (normotensive). Complete the flow chart entitled Mild blood loss, which can be found later in this section of the workbook, to explain how the baroreceptor reflex acts to maintain her blood pressure after blood loss. How would this persons pulse feel? Case study two A 12 month old boy, Adam, has been vomiting and has had diarrhoea for the past 24 hours and has become dehydrated. This overall loss of fluid causes a drop in Adam s blood volume. The nurse takes his pulse (tachycardic) and blood pressure (hypotensive). Create your own flow chart to show how the baroreceptor reflex acts in this case. 85

88 Case Study One Complete the flow diagram below by deleting the incorrect answer (for example blood loss causes an increase / decrease in blood volume) MILD BLOOD LOSS Decrease in blood volume BARORECEPTORS detect an Increase/decrease in blood pressure Decreased/Increased rate of nerve impulses to MEDULLA CARDIOVASCULAR CONTROL CENTRE AUTONOMIC NERVOUS SYSTEM Sympathetic stimulation or Parasympathetic stimulation or HEART Heart rate or Stroke volume or cardiac output or ARTERIOLES Dilate or constrict peripheral resistance or TACHYCARDIA or blood pressure NORMOTENSIVE 86

89 Circulatory System Systemic vessels Transport blood through most all body parts from left ventricle and back to right atrium Pulmonary vessels Transport blood from right ventricle through lungs and back to left atrium Blood vessels and heart regulated to ensure blood pressure is high enough for blood flow to meet metabolic needs of tissues 1. HEART RATE - Pulses per minute 2. STROKE VOLUME - Amount of blood expelled from ventricle each time it beats CARDIAC = HEART RATE X STROKE VOLUME OUTPUT ml/min beats per min ml Heart rate can change... What makes HR? What makes HR? What controls these increases and decreases in heart rate? AUTONOMIC NERVOUS SYSTEM (ANS) Connections to SA node 2 Branches of the ANS SYMPATHETIC NERVOUS SYSTEM PARASYMPATHETIC NERVOUS SYSTEM STROKE VOLUME - Amount of blood expelled from ventricle each time it beats - Strength of contraction What is it affected by?.. Amount of blood that enters the heart during diastole BLOOD PRESSURE - What is it?... Increase diastolic time Increase blood volume Increase stretch Increase contraction Stroke volume depends on blood volume Severe blood loss- How would it affect.. Filling Contraction Stretching Stroke volume Pressure of blood against the walls of the vessel Units = mmhg or kpa (kilopascals) 87

90 Blood = Cardiac Vascular X Pressure Output Resistance SV HR Cardiac output amount of blood pumped by heart in one minute What aspects of the vessel can affect BP? Length of the vessel Viscosity of blood Daimeter of vessel Sympathetic stimulation Vascular resistance ease of pushing the blood through the vessels VASODILATION NO Sympathetic stimulation VASOCONSTRICTION Baroreceptor Reflex Pe-reading see blood pressure material on web site Control of Blood Pressure via the Baroreceptor Reflex brain cardiovascular centre baroreceptors on aorta and carotid sinus send information about changes in BP to cardiovascular centre sympathetic innervation of arterioles heart arterioles sympathetic innervation of myocardium sympathetic and parasympathetic innervation of sino-atrial node KEY parasympathetic nerves sympathetic nerves afferent sensory nerves 88

91 To review circulatory physiology, answer the following questions using the information you have gained from your pre-reading, your notes and the tutorial: 1. Why is it important to maintain a constant blood flow? 2. What are the functions of the circulatory system? 3. Which type of cell transports oxygen around the body? 4. Fill in the following gaps to describe the flow of blood through the heart ORGAN LUNGS ORGAN 5 a. Which blood vessels carry oxygenated blood? b. Which blood vessels carry deoxygenated blood? 6. What maintains unidirectional flow in the heart? 7. What sets the rhythm of the heart? 8. What effect does adrenaline have on heart rate and blood pressure? 9. Does parasympathetic innervation of the heart increase or decrease heart rate? 10. What diagnostic test is used to detect the location of a myocardial infarction (heart attack)? 11. Where are the baroreceptors located and what is their function? 89

92 Section 4: Introduction Following the administration of chemotherapy, Margaret is feeling very unwell; she has had diarrhoea & vomiting for 5 days and she is reluctant to eat or drink in case she is sick again. If Margaret had a learning disability she may need help in completing the admission process. It may be that her communication profile (how she communicates, how you know she is happy/sad/in pain, level of understanding etc) will be shared with ward staff. Desensitisation programmes may be introduced if necessary. For example if Margaret appears frightened of having her blood pressure taken she will be shown what will happen through role-play or being shown the equipment and talking about the procedure prompted by the use of photographs. If Margaret has no family and lives independently, a member of the CLDT will visit her in hospital. In this section you will consider the digestive system as self-directed study, digestive physiology, nutrition & feeding, renal physiology, dehydration & fluid balance including universal precautions and pressure ulcer prevention. These will include both physiology and nursing skills. 90

93 Session 13: Digestive System Diet and Health The Digestive System You are what you eat! Nutrients required:- Raw materials for growth and repair As energy sources For biochemical processes There are 5 main groups of nutrients required Carbohydrates, fats, proteins, vitamins, minerals. Water and fibre are also required but these are not classed as nutrients. 1 2 Dietary Requirements Depends on many factors including Age Body size / lean body mass Gender Activity levels Pregnancy / Lactation Fever / Trauma / Major surgery Nutritional individuality Digestive Process [1] Ingestion Taking food into the digestive tract [2] Propulsion Move food through alimentary canal [3] Digestion Breakdown of food [4] Absorption Digested end products (+minerals, vitamins and water) absorbed into blood and lymph supply [5] Defecation Excretion of indigestible food and metabolic waste 3 4 Digestion Breakdown of huge food molecules into small ones Digestive Tract (Alimentary Canal) Digestion Chemical Mechanical

94 Organs Of The Digestive Tract Mouth Pharynx Oesophagus Stomach Small intestine Large intestine Mouth Site for mechanical and chemical digestion Teeth accomplish mechanical digestion by chewing (mastication) Chemical digestion is achieved by saliva produced by salivary glands Functions Of Saliva Saliva begins digestion of carbohydrates in mouth by salivary AMYLASE Saliva facilitates swallowing by moistening food particles via mucus (thick and slippery) Anus 7 8 Saliva possesses antibacterial action Rinsing away material that may serve as food source for bacteria. Bicarbonate in saliva neutralizes acid in food. Body Stomach Fundus Saliva is neither sugary or salty important for perceptio of sweet and salty tastes. 9 Antrum 10 Functions Of The Stomach Main function of stomach is storing ingested food until it can be emptied into small intestine at a rate appropriate for optimal digestion and absorption. Second function is secretion of hydrochloric acid HCl and protein-digesting enzymes PROTEASES Final product from the stomach is CHYME Pancreas Accessory digestive organ Secretes amylase, proteases and LIPASE into the small intestine Lipase aids in fat digestion 11 Liver & Gallbladder Liver secrets a substance called BILE Bile helps in fat breakdown (like liquid soap) Bile is stored in the gallbladder and then released into the small intestine Small Intestine Coiled between stomach and large intestine Duodenum, Jejunum and ileum SITE OF DIGESTION AND ABSORPTION 12 92

95 Inner surface of small intestine is lined by finger-like projections VILLI Villi increase the surface area available for absorption Large Intestine Consists of: 1) Cecum 2) Appendix 3) Colon 4)Rectum Large intestine absorbs more water and salt and stores faeces Absorptive & Storage Functions Of The Colon 15 93

96 Session 14: Nutrition and Feeding For the Nutrition and Feeding skills session you are required to bring some sloppy food e.g Yoghurt and spoon. Introduction This topic will consider the functions of nutrients that are required to maintain physiological functions and health. It is useful for you as a nurse to consider how these nutrients are digested and absorbed, as there are conditions that affect gut motility, activity of digestive enzymes and absorption. These will affect a patient's health and their ability to recover from illness. The lecture and tutorial sessions will consider the physiological consequences of altered digestion and nutrient deficiencies to health that may be applied to clinical practice. At the end of these sessions, you should be able to: Name the components of the digestive system, including the accessory digestive organs. Describe how digestive enzymes facilitate breakdown of carbohydrates, lipids and proteins. Understand the process of absorption Identify the functions of the main nutrients in the diet. Describe how body mass index (BMI) may be used to assess nutritional status. Consider the consequences of particular nutritional deficiencies and excesses to health. The following nutrition websites will be of use in completing worksheets and the case studies on this topic: Links to nutrition websites: British Nutrition Foundation: The Vegetarian Society: European Food Information Council: Digestive Disorders Foundation: British dietetic association (BDA): British Association of Parenteral & Enteral Nutrition (BAPEN) Further Recommended Reading Most physiology textbooks include sections on nutrition. In addition to these, the following textbooks available in the library will be of use: Davis, J., Sherer, K. (1998) Applied Nutrition and Diet Therapy for Nurses W.B. Saunders Company 2 nd edition Fieldhouse, P (1998) Food, Nutrition, Customs and Culture Stanley Thomas 2 nd edition Garrow, J.S., James, W.P.T., Ralph, A (2000) Human Nutrition and Dietetics, Churchill Livingstone, 10 th edition Mann, J., Truswell, A.S (1998) Essentials of Human Nutrition Oxford university press Shaw, V., Lawson, M. (2001) Clinical Paediatric Dietetics Blackwell publishing 2 nd edition Thomas, B. (1996) Nutrition in primary care a handbook for professionals Blackwell Science Whitney, E. Cataldo, C. DeBruyne, L, Rolfes,S. (2001) Nutrition for Health and Health care Wadsworth 2 nd edition 94

97 NUTRITION AND DIGESTION Self Directed Activity Read the following background information prior to the session Nutrition is concerned with digestion, absorption, transport, metabolism and biochemical functions performed by individual chemical substances that are obtained from macronutrient and micronutrient components of our diet. The food that we ingest in the diet contains nutrients that are broken down by digestion and absorbed from the digestive tract into the bloodstream. These nutrients have a variety of functions as outlined below: 1. They provide energy (in the form of ATP) for metabolic processes. 2. They can provide building blocks for new biological molecules that are used for growth and repair of tissues. 3. They are involved in various biochemical processes that occur in our cells and tissues An adequate intake of nutrients is required to maintain health. Functions of Nutrients in the Diet 1. Carbohydrates The main function of carbohydrates is to provide energy for the body. Energy is stored in the chemical bonds of these nutrients. This energy is measured in kilocalories (kcal). There are 3 groups of carbohydrates: Monosaccharides, including glucose, fructose and galactose Disaccharides, including sucrose, lactose and maltose Polysaccharides (complex carbohydrates), including cellulose (dietary fibre), glycogen and starch During digestion, the polysaccharides and monosaccharides are broken down into monosaccharides that can be absorbed into the blood. Humans cannot digest the cellulose that forms the cell walls of plants. This forms dietary fibre, which is essential to maintain gut motility. 2. Lipids The lipids that we ingest in the diet perform a number of functions, in addition to providing energy: 1. Store energy in the body. 2. Insulation. 3. Cholesterol is a precursor of steroid hormones, such as oestrogen and testosterone. 4. Cholesterol can be modified to produce bile salts 5. Phospholipids and cholesterol are components of plasma membranes in cells 6. Phospholipids contribute to construction of the myelin sheath around the axons of neurons. 7. Lipids carry fat-soluble vitamins Approximately 95% of lipids in the human diet are triglycerides (often referred to as fats). These can be divided into saturated and unsaturated fats. The remaining 5% of lipids in the human diet include cholesterol and phospholipids that are both components of the plasma membrane of cells. Cholesterol is also needed for the synthesis of steroid hormones. During digestion, triglycerides are broken down into glycerol and fatty acids. These fatty acids are 95

98 taken up and used by various tissues to produce energy. Excess triglycerides that are not used as an energy source are stored in adipose tissue. 3. Proteins Proteins perform a range of functions in the human body, including: 1. Structural proteins, such as actin and myosin in muscle, and keratin in skin. 2. Enzymes speed up (catalyse chemical reactions). 3. Carrier molecules to transport substances across cell membranes. 4. Receptors and ion channels in plasma membranes. 5. Haemoglobin transports O 2 and CO 2 in the blood. 6. Antibodies that fight infection are proteins. 7. Some hormones are proteins. 8. Proteins can be used as a source of energy. Proteins consist of chains of amino acids that are linked together by peptide bonds. During digestion, digestive enzymes break the peptide bonds and the amino acids are absorbed into the blood. Whilst some amino acids can be produced in the body, others are essential amino acids that the body cannot produce and that must be ingested in the diet. Examples of essential amino acids include phenylalanine, tyrosine, tryptophan and valine. 4. Vitamins Vitamins are organic molecules that are required in small amounts for growth and to maintain health. Deficiencies of vitamins will therefore affect growth and health. These vitamins are required to help to make use of proteins, carbohydrates and lipids as building block for other molecules and to help to use these as an energy source. As most vitamins are not made in the body, they must be ingested in the diet or as dietary supplements. One vitamin that can be synthesised in the body is vitamin D that can be synthesised in the skin. Also, there are bacteria in the large intestine that can synthesise B complex vitamins and vitamin k. There are two main categories of vitamins: 1. Water-soluble vitamins are absorbed along with water from the gastrointestinal tract - B vitamins, folic acid and vitamin C. They are not stored in the body to any great degree so need to be replaced daily. 2. Lipid-soluble vitamins are bound to lipids that are ingested in the diet and are absorbed from the digestive tract along with the breakdown products of lipids. Lipid-soluble vitamins may be stored in the body, mostly in the liver - vitamins A, D, E and K and so deficiency is less common. 5. Minerals Minerals are inorganic substances that need to be ingested in the diet to maintain metabolic functions in the body, to add mechanical strength to bones and to combine with other substances to act as buffers and osmotic regulators. Minerals may be ingested on their own or in combination with organic molecules. Major or macrominerals (e.g. calcium, iron and sodium) are required in larger quantities than trace minerals (e.g. iodine and zinc). Deficiencies of minerals can affect health. For example, dietary deficiency of iron may result in anaemia and deficiency of iodine can affect thyroid hormone function. Excess intake of sodium can result in the development of hypertension. 96

99 Questions 1. What is the recommended composition of our diet As a percentage, how much of our diet should be carbohydrate based? 2. What percentage of our diet should be protein? 3. How much fat (as a percentage) should our diet contain? The diet of the general population needs some improvement and the government is trying to address this issue. Look at the following table to see which specific components of our diet are being targeted. The Department of Heath recommend the following based on data obtained from the COMA (Committee on Medical Aspects of Food and Nutrition Policy) report Actual intakes are based on the National Food Survey (1999). This only assesses food eaten in the home so this may underestimate intakes. Key nutrient intake Recommended average Actual average intake intake Saturated fat Reduce to no more than 10% 14% Total fat Reduce to no more than 35% 37% energy Poly-unsaturated Fatty Increase to 0.2g/day (1.5g/wk) 0.1 Acids (Omega 3 oils) Complex carbohydrates Increase to approx 50% 45% Added Sugars (simple No more than 10% energy per 13% sugars) day Dietary fibre Increase in NSPS to 18g/day Increase from a variety of sources 12g/day Sodium (salt) Dietary cholesterol Maintain healthy body weight Fruit and vegetable consumption Red and processed meat Reduce to no more than 6g/day 254mg/day BMI 20-25Kg/m 2 Increase by 50% to at least 5 portions a day Adults who eat more than average might benefit from a reduction 9g/day 217mg/day 40% of adults are overweight 21%are obese 3-4 portions per day Please read the following article to help you answer the questions below. Nutrition and Cancer Taken from O Brien N and O Connor T (2002) Nutrition and Cancer. Cancer Nursing Practice. 1 (8) Most cancers are chronic diseases that develop in the human body over many decades. It is widely accepted that the majority of cancers are caused and/or influenced by environmental factors including tobacco use and dietary factors. It therefore follows that many cancers may be preventable. 97

100 Cancers represent the second most common cause of death in developed countries after cardiovascular diseases. Typically cancers account for between 20 and 25% of all deaths. Cancers of the lung, large bowel, breast, stomach and prostate are most commonly seen in developed countries. In creasing age increases the risk of cancer at most sites worldwide but age adjusted cancer rates differ dramatically in different part of the world. For example, cancer of the colon is twenty times more common in the USA compared to India. Different rates of cancer are now thought to be due to different environmental factors rather than different genetic factors. On average between 30 and 35% of all cancers might be prevented by appropriate dietary change. Excluding skin cancer, lung cancer is the most common cancer worldwide. The principal and overwhelming factor in the development of lung cancer is the use of tobacco products. Increased intake of fruit and vegetables also has a weak protective effect. People eating low levels of fruit and vegetables have about twice the risk of developing lung cancer, while those smoking a pack of cigarettes a day for about 20 years have about 20 times the risk. There is also some evidence that high meat consumption may increase lung cancer risk. Evidence exists that high intakes of fruit and vegetables are associated with decreased risks of developing many cancers including colon cancer, stomach cancer and cervical cancer. The Department of Health (DOH 1998) has issued dietary recommendations to reduce cancer risk. To maintain a healthy body weigh to within the body mass index (BMI) range between 20 and 25 kg/m2 and not to increase it during adult life. To increase intake of a wide variety of fruit and vegetables. To increase intake of dietary fibre from a variety of food sources. For adults, individual s consumption of red and processed meats should not rise. Consumers of high quantities should consider a reduction. These recommendations should be followed in the context of a balanced diet rich in cereals, fruit and vegetables. These dietary recommendations are also consistent with recommendations to reduce the risk of cardiovascular disease. Reference. Department of Health (19980 Nutritional aspects of the development of cancer. A report of the COMA panel on diet and cancer. London. The Stationary Office. Questions Please answer the following questions in groups. 1. The article above confirms evidence exists that high intakes of fruit and vegetables are associated with a reduced risk of developing bowel cancer. Fruit and vegetables contain fibre. What other specific foods are rich in fibre? 2. What physiological effect does fibre have on the colon? 3. What effect will a lack of dietary fibre have on bowel motility? 98

101 4. Some fruit and vegetables are high in the anti-oxidant vitamins A, C & E. Antioxidants are thought to counteract the damaging effects of carcinogenic agents in the body (including those ingested in the foods we eat) and protect against cancer. Which specific fruit and vegetables are rich in these vitamins may provide this protective effect? 5. Constipation can increase the exposure of metabolic wastes, undigested food and food contaminants (including carcinogenic agents) in the large bowel. This exposure can increase the risk of bowel cancer developing. Can you think which section of the colon is at most risk of developing cancer? 6. What symptoms might present with constipation (what will patients complain of feeling?) 7. Gastro-intestinal cancers can cause obstruction in the gut. How will this obstruction affect the following..circle the correct answer and provide a reason for each answer. a) Mechanical digestion Increase / Decrease b) Chemical digestion Increase / Decrease c) Absorption Increase / Decrease Margaret is having chemotherapy to treat her lung cancer. Chemotherapy can have significant effects on the digestive system such as mucosal damage, vomiting and diarrhoea. 8. What do you understand by the term mucosal damage? 9. Can you think of any effects that could occur in Margaret s mouth as a result of oral mucosal damage from her chemotherapy? 10. How might persistent vomiting and diarrhoea affect Margaret s physiological state and health? 99

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105 Self-Directed Activity Session 14a: Pressure Ulcers This is a self-directed study session & should take two hours of your self-directed study time (150 hours total) Resources to complete this session: European Pressure Ulcer Advisory Panel Gebhardt, K. (2002) Pressure Ulcer Prevention: Part 2 Patient Assessment. Nursing Times 98(12) pp: Dealey, C. (2005) The Care of Wounds: A Guide for Nurses. 3 rd Edition. Oxford. Blackwell Publishing. pp: Incidence of Pressure Ulcers: 15% of patients in acute hospitals are affected. Up to 30% of orthopaedic and elderly care patients are affected. 95% of pressure ulcers can be prevented. (Dealey 1997) Pressure Ulcers: Pressure ulcers are also commonly known as pressure sores, bedsores and decubitus ulcers. Pressure ulcer is the term preferred for European consensus. The European Pressure Ulcer Advisory Panel (2000) gives the definition: A pressure ulcer is an area of localized damage to the skin and underlying tissue caused by pressure, shear, friction and or a combination of these Damage is caused by a disruption to the blood supply to an area of tissue, preventing oxygen and vital nutrients reaching the cells in that area. If the pressure is unrelieved, the resulting ischaemia can lead to cell death and tissue necrosis. (Clarke 1999) Ischaemia Restricted blood supply to an area of tissue Necrosis Type of cell death Another important consequence of pressure sores is risk of Inflammation Inflammation is a mechanism designed to contain and isolate injury and prevent spread of harmful organisms. It also prepares the tissue for healing and repair. However, it maybe potentially harmful to the body as inflamed tissue can easily become infected. Inflammation is defined as Non-specific coordinated response by vascularised living tissue to injury Inflammation may be acute (short duration) or chronic (long duration). Inflammation involves release of soluble mediators, increased blood flow, increased permeability, migration of immune cells and elevated cellular metabolism. The four common symptoms of inflammation are as follows: Heat Redness Pain Swelling 103

106 Causes of Pressure Ulcers Pressure: Continuous pressure to an area of the body, especially over a bony prominence, above 32mmHG interrupts the vascular supply of nutrients and oxygen to tissues and cellular damage occurs as a result. Shearing: Opposing lateral forces that occur when a person slides down the bed or chair create a shearing effect within the soft tissue. Superficial tissues remain static against the support surface, other various layers of the skin move over one and other causing tissue distortion.(pedley 1998) The shear forces may also close off the valves in the lymphatics and this combined with tissue ischaemia can accelerate tissue necrosis and development of a pressure ulcer. Friction: Skin damage caused by friction typically occurs when the skin has rubbed against another surface, for example, elbows and heels rubbing against a sheet. Friction causes the epidermis to be stripped away, creating shallow dermal ulcers or blistering. (Clay 2000) Sores caused by friction, although relatively superficial, are usually painful and make the skin more prone to pressure damage. (Simpson et al 1996) Maceration: Literally means the softening of a solid by leaving it immersed in a liquid (Oxford Medical Dictionary 1998) Moisture weakens the natural barrier of the skin and softens it, increases the likelihood of skin maceration. Pressure Ulcer Grading: Stage 0: Blanching erythema Stage 1: Non-blanchable erythema, light finger pressure applied to the site does not alter discolouration of intact skin. Stage 2: partial thickness of skin loss involving epidermis and / or dermis. Stage 3: full thickness of skin loss involving damage or necrosis to the subcutaneous layer but not extending to underlying bone or tendon Stage 4: full thickness of skin loss with extensive destruction extending to bone or tendon. Activity: Please go to the Pressure Ulcer Advisory Panel web site, read the theory & take the on-line test. Use the following address: Pressure Ulcer risk factors: (Intrinsic) Mental Health Dehydration Age Incontinence Immobility Complicating diseases Malnutrition Weight Loss Other Physical problems 104

107 Prevention & management is based upon: Improving tissue resistance to pressure Preventing damage to skin Elimination of damaging pressure Nursing Actions Assessment Nutritional assessment & meeting nutrition & hydration needs Meeting hygiene needs Managing excess moisture to skin i.e. incontinence, perspiration, excessive wound drainage Careful positioning and regular position change Careful moving & handling Clean, dry bedding & crease & crumb free sheets Care of mattresses Use of specialized equipment. Activity: Without referring back to your workbook, try to answer the following questions: 1: Damage occurs to the skin as a result of? 2: What signs would lead you to suspect there is inflammation? 3: What is the preferred term for European consensus? 4: How would you describe a stage two pressure ulcer? Using the suggested resources answer the following: 5: Give the names for three different assessment tools used to assess the risk of developing pressure ulcers. 6: Suggest some strategies for preventing pressure ulcer development. Reflection: Take some time out & consider what are you have gained from your self-directed study. What knowledge did you possess prior to completing this work? What do you know now? What further learning is needed? 105

108 Session 15: Renal System This lecture will introduce key concepts of renal function that will provide the basis for further discussion in the urinalysis tutorial. By the end of this lecture you should be able to: Describe the structure and function of the kidneys and nephron Explain the process of glomerular filtration, reabsorption and secretion and indicate where these processes occur in the nephron. The next few pages include the diagrams and lecture notes that will be covered in the lecture. Further explanation will be provided in the lecture. 106

109 An introduction to the Renal system How does the kidney help maintain homeostasis?? Removal of metabolic wastes Maintaining the water and electrolyte balance of blood Maintaining the ph of blood Production of erythropoietin which stimulates RBC production Production of renin which helps regulate blood pressure and kidney function Medulla 107

110 Blood supply to nephron. An afferent arteriole supplies the glomerulus with blood. The glomerulus is a knot of blood capillaries. Blood is drained from the glomerulus by an efferent arteriole into into:. Peritubular blood capillaries surrounding those parts of the nephron which are in the renal cortex. Mechanisms of urine formation Specifically each nephron performs; 1. Ultrafiltration of blood. 2. Selective reabsorption * 3. Selective secretion * * Some elements are under Hormonal control Ultrafiltration Ultrafiltration results in the movement of fluid from the blood (glomerulus) into the nephron (Bowman s capsule) Blood pressure within the glomerulus is the only force which drives fluid into the nephron. Blood flows through the glomerulus at high pressure due to Efferent arterioles have a smaller diameter than afferent arterioles High resistance offered by efferent arterioles Fluid must flow through the glomerular membrane made up of three layers CAPILLARY ENDOTHELIUM BASEMENT MEMBRANE FOOT PROCESSES OF PODOCYTES 1) Endothelial cells. These form the wall of the glomerular blood capillaries with small gaps between. 2) The basement membrane of the endothelial cells. This consists of a fine mesh of connective tissue proteins. 3) Podocytes. Inner layer of bowmans capsule, create small gaps aiding ultrafiltration. FENESTRATION FILTRATION SLIT 108

111 BLOOD Large molecules. Reabsorption & Secretion Indicate The Direction Of Movement Of A Molecule Across The Cell Membranes Of Epithelial Cells Lining The Nephron. Reabsorption Ultrafiltration Barrier. Filtrate Secretion Blood Filtrate In The Nephron. Small molecules. Blood Filtrate How Does Selective Secretion & Selective Reabsorption Aid In Maintaining Homeostasis. Selective reabsorption ( SAVES ). If the body is deficient in a molecules it tends to be selectively reabsorbed from the filtrate. Selective secretion ( Excretes ). If a substance is present in excess within the body it tends to be selectively secreted into the nephron, to pass into urine and be excreted. Reabsorption Useful molecules, present in the filtrate, are reabsorbed e.g. Amino acids (normally 100%): Glucose (normally 100%)., Ions such as: Sodium ions (approx 70%) Chloride ions (approx 70%) Potassium ions (approx 70%) Water is also reabsorbed by osmosis Secretion Important for disposing of substances not already in filtrate e.g Hydrogen ions Potassium ions Certain drugs (penicillin) urea 109

112 Session 16: Dehydration and Fluid Balance Margaret had undergone chemotherapy in an attempt to treat her tumour. One of the side effects of chemotherapeutic drugs was excessive diarrhoea and vomiting. Margaret was advised to eat meals that are without strong odour. Her Physician also recommended she ingested small meals more frequently. As time progressed, Margaret became lethargic and was diagnosed with anaemia and hypotension. You may need to review the notes from the nutrition and feeding session in addition to the slides provided below. Dehydration, Diarrhoea & Vomiting Motility Of The Large Intestine Motility is stimulated by the parasympathetic division of the autonomic nervous system. Types of Motility [1] Peristalsis [2] Segmentation [3] Mass movements Function Of The Large Intestine 1 Large intestine absorbs more water and salt and stores faeces Defecation Faeces contains: Dietary fibre Sloughed dead cells from the gut wall Water Ions Fat Bile pigments (responsible for colour of faeces) Defecation reflex is initiated by distension of the rectum Fluid Balance Critical to maintain balance between volume of fluid ingested and volume of fluid lost Fluid may be lost via several ports in the human body Dehydration may result from: a) Lack of fluid intake b) Excessive fluid loss 110

113 Diarrhoea Production of watery faecal material Antidiuretic Hormone May be a protective mechanism to expel a foreign pathogen outside the body Vomiting Unpleasant experience that causes stomach emptying via a different route Process of vomiting is mediated via the emetic centre in the medulla Vomiting like diarrhoea may act as a protective mechanism Water loss ADH secretion stimulated Increased permeability of distal convoluted tubule and collecting tubule Increase water reabsorption into the blood Defaecation Intestinal contents become increasingly solid as water is absorbed. Peristalsis and mass movements propel the contents through the large intestine, towards the rectum. The defecation reflex is initiated by distension of the rectum. Rectal distension also induces the voluntary desire to defecate Defaecation Reflex 1. Distension of the rectum stimulates stretch receptors in the rectal wall. This sensory information is sent to the spinal cord. 2. Parasympathetic neurons then stimulate contraction of the rectum, increasing the pressure in the rectum. 3. The internal anal sphincter (involuntary smooth muscle) relaxes. This is the involuntary reflex that results in defaecation in young children for example. 4. When the time is appropriate, motor neurons send a signal to the external anal sphincter (voluntary skeletal muscle) and it relaxes. Complete development of these motor neurons and hence bowel control can take time. Refer to Marieb, E. N. (2004) Human Anatomy & Physiology. Benjamin/ Cummings. Chapter 23;figure the defaecation reflex for an illustration of this nervous pathway. Fluid Balance It is critical that we maintain a balance between the volume of fluids ingested and the volume of fluids lost. Dehydration may result from lack of fluid intake. Alternatively, there may be excessive fluid loss. Fluid may be lost via several ports in the human body. These include sweating (100 ml/day), urine (1.2 litres per day) and respiration. Excessive fluid loss may accompany a variety of pathological situations such as diarrhoea and vomiting. Diarrhoea Approximately, a 100 ml of water is lost through faces daily. This amount will increase with diarrhoea. Diarrhoea may be caused by ingestion of contaminated food material. This makes it a protective mechanism in trying to expel the foreign pathogen outside the body. 111

114 Other causes of diarrhoea may relate to diseases of malabsorption. A classical example of this is lactose intolerance. In a lactose intolerant individual, the sugar lactose accumulates in the small intestine and draws in water by the process of osmosis. This limits the amount of water that could be absorbed by the small and large intestine resulting in diarrhoea. Vomiting Like diarrhoea, vomiting may also act as a protective mechanism by expelling harmful substances from the body. Many signals stimulate the stomach to launch lunch. The most common include extreme stretching of the stomach (over eating), presence of bacterial toxins, unpleasant odours, stressful situations, excessive alcohol and drugs. The process is mediated via the vomiting centre (or emetic centre) in the medulla. This results in muscles of the stomach, abdomen and diaphragm to contract, thereby increasing the pressure in the stomach and helping to expel the vomitus. Risks Associated With Diarrhoea and Vomiting Disturbances in the electrolyte and acid-base balance may arise from prolonged vomiting and / or diarrhoea. Large amounts of hydrochloric acid are lost in the vomitus, the blood becomes alkaline as the stomach attempts to replace its lost acid. Large amounts of bicarbonate ions are lost through diarrhoea, causing the blood to become acidic. In addition to the large volumes of water lost during the processes of diarrhoea and vomiting, essential vitamins and minerals may also be lost. Macrominerals (e.g. sodium and potassium, calcium and iron) are required in larger quantities than trace minerals (e.g. iodine and zinc). Deficiencies of all minerals can affect health, but Sodium and Potassium imbalances are most common. Loss of Sodium and Potassium can affect the Nervous System. The Nervous System is a very important control system in the body, passing electrical impulses (also known as action potentials) from one nerve cell (neuron) to the next. This involves changes in the concentrations of sodium and potassium ions across the neuronal membrane. Loss of sodium or potassium will disrupt this mechanism and therefore disrupt the conduction of the electrical message down the nervous system. Deficiency in Iron may result in anaemia. This is because iron is a major constituent of haemoglobin in red blood cells. Calcium is required in the process of osteogenesis (bone formation). It is also critical for maintaining the electrical activity of the heart. Loss of calcium may result in brittle bones and defects in the heart rhythm (cardiac arrhythmias). The loss of fluid associated with diarrhoea and vomiting may also result in hypotension. Physiological Response to Fluid Loss One of the ways the body responds to excessive fluid loss is by the secretion of antidiuretic hormone (ADH). Antidiuretic hormone is secreted by the posterior pituitary gland in response to loss of fluid in the body. ADH functions at the level of the kidney where it increases water reabsorption back into the blood and reduces the volume of urine produced and excreted. 112

115 Now, try answering the following questions: 1. Using a simple explanation, why may chemotherapy result in excessive diarrhoea and vomiting 2. State three factors that may induce diarrhoea and vomiting 3. State two reasons why Margaret developed anaemia 4. Why might vomiting result in disturbances in acid-base balance? 5. Fluid may be lost via several ports in the human body. Diarrhoea and vomiting are two examples. Name three other methods of fluid loss in humans. 113

116 Session 17: Psychological Impact on Health 114

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120 Section 5: Introduction Due to her immunosuppression, Margaret is at an increased risk of infection. She has developed a slight temperature; the doctor asks for a sputum specimen and a mid-stream specimen of urine to be sent to microbiology for MC & S. If Margaret had a learning disability The CLDT member or care staff, will liase with the district nurses regarding any nursing care & support that she may need. If Margaret lives independently the Community Living Service will provide additional support, for example hoovering, help with personal hygiene & shopping. In this section you will consider the procedure for taking a temperature & the physiology related to temperature control as self-directed study, physiology and temperature tutorial, urinalysis & obtaining samples tutorial. 118

121 Session 18: Temperature Regulation Link Session Following Margaret s first course of chemotherapy, she developed a high temperature and began to feel unwell. In this tutorial we will look at ways in which temperature is controlled and how this may become altered during an infection. We will also look at ways in which nursing staff may take a patients temperature, and how they may care for a patient with a high, or low temperature. By the end of this session you should be able to: Temperature Regulation Link Session Describe how core temperature is maintained by homeostasis. Explain how infection results in pyrexia Lists ways in which nursing staff may take a patient s temperature. Discuss ways of caring for patients with a high, or low, temperature. Taking a Temperature. What is the difference between core and peripheral temperature? Think of some sites that could be used to record a client s temperature, Suggest which may be most appropriate for each branch of nursing and why. Which will provide the most accurate recording? For each branch of nursing, suggest when you might take someone s temperature. Temperature Regulation Core temp maintained by homeostasis Average temperature (set point) determined by thermoregulatory centre in hypothalamus, Temperature monitored by thermoreceptors Central thermoreceptors in hypothalamus. Peripheral thermoreceptors are in the skin. Thermoreceptors send impulses to thermoregulatory centre. 119

122 Questions???? The body can lose heat by convection, conduction, radiation and evaporation. Which of these increases heat loss when you; Sweat? Open a window? Walk barefoot? Have a flushed face? Negative Feedback and temperature regulation When thermoreceptors detect a rise in core temperature, changes occur to return it to the set point, When thermoreceptors detect a drop in core temperature, changes occur to return it to the set point. Negative feedback Suggest some changes that may occur in each case. T E M P E R A T U R E O F E X T E R N A L E N V IR O N M E N T B O D Y T E M P E R A T U R E or NEGATIVE FEEDBACK TH ER M O R ECE P TO RS S K I N A N D H Y P O T H A L A M U S or R ate of nerve im pulses IN P U T B R A I N T H E R M O R E G U L A T O R Y C E N T R E S or Rate of nerve im pulses via sym pathetic or parasym pathetic nerves OUTPU T EFFEC TOR S SW EAT GLANDS BLO OD VESSELS IN SKELETAL SKIN MUSCLES S W E A T P R O D U C T IO N CO N S TR IC T O R DILATE C O N T R A C T O R R E L A X or ( S H IV E R IN G ) or BLOO D FLOW INCR EASE OR DEC REASE IN B OD Y TEM PER ATU RE Margaret s first admission Margaret s first admissionquestions Margaret came into hospital for her first course of chemotherapy. What are the highest and lowest temperatures recorded? At which time of day is Margaret s temperature lowest? Why? Roughly what is Margaret s set point? Why is her temperature fluctuating? Does Margaret show hypothermia, hyperthermia or normothermia? 120

123 Margaret s Readmission Margaret has an infection Margaret was readmitted a week after her chemotherapy course had been completed. She felt shivery and very unwell; Margaret has pyrexia due to an infection, Bacteria and white blood cells trigger the hypothalamus to make a substance called prostaglandin, which raises the set point. What is Margaret s set point now. Suggest why she feels shivery. Suggest how chemotherapy has resulted in Margaret s infection. What would you class as a pyrexia? Hyperpyrexia? Treatment for Margaret Suggest how each of the following may help Margaret initially; Anti-pyretics, (eg.paracetamol, inhibit prostaglandin production.) Antibiotics Suggest why fan-therapy and tepid sponging was not recommended. What other nursing interventions could you use when caring for Margaret? Neonates and incubators. Neonates tend to lose heat; They are small with a large skin surface compared to their size, They have little subcutaneous fat, They have a limited ability to shiver, or sweat, They have an immature hypothalamus. Neonates have areas of brown fat they can be activated to generate heat if they get cold This uses up food and oxygen Suggest why premature neonates may be cared for in an incubator at first. Hypothermia Apart from neonates, which other groups are at risk of hypothermia? When would you class someone as hypothermic? What signs and symptoms may you see in someone with hypothermia? How would you care for someone suffering from hypothermia? Summary Can you now; Describe how core temperature is maintained by homeostasis? Explain how infection results in pyrexia? Lists ways in which nursing staff may take a patient s temperature? Discuss ways of caring for patients with a high, or low, temperature? 121

124 TEMPERATURE OF EXTERNAL ENVIRONMENT BODY TEMPERATURE or NEGATIVE FEEDBACK THERMORECEPTORS SKIN AND HYPOTHALAMUS or Rate of nerve impulses INPUT BRAIN THERMOREGULATORY CENTRES or Rate of nerve impulses via sympathetic or parasympathetic nerves OUTPUT EFFECTORS SWEAT GLANDS SWEAT PRODUCTION or BLOOD VESSELS IN SKIN CONSTRICT OR DILATE or BLOOD FLOW SKELETAL MUSCLES CONTRACT OR RELAX (SHIVERING) INCREASE OR DECREASE IN BODY TEMPERATURE 122

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126 Session 19: Urinalysis Clinical Urine Testing Urine testing using a reagent strip is a non-invasive, economical and reliable means of identifying signs and symptoms of a number of diseases in their early stages, provided that the procedure is accurately followed (Halloran & Bennett, 1999; Torrance & Ellery 1998a; Anonymous, 1999) Urinalysis may be useful to: Determine the individual s urine status on admission as a baseline for comparisons with future assessments Monitor changes in urinary constituents as a response to medication Be used as a screening test to gather information about physical condition (Mallett & Dougherty 2000) Procedure Explain the specimen collecting procedure to the patient/client and ensure understanding. The patient/client should be asked to produce a clean specimen of urine for a routine urinalysis using reagent strips. This can be collected in a non-sterile container such as a plastic sample bottle, disposable bedpan or urinal. If the specimen is likely to require further laboratory testing the sample must be collected in a plastic sample bottle and a mid-stream specimen of urine should be obtained (see box 1). Be aware of communication difficulties, use of jargon and cultural attitudes towards handling and collection of body fluids, be sensitive to any wishes the patient/client may have (Anonymous, 1999; Cook, 1996; Mallett & Dougherty 2000). Urine is a potential biohazard and should be handled with care. Whilst performing the reagent strip test take care not to contaminate the bottle or surrounding area, always wear gloves and handle reagent strips by the non-impregnated end.(halloran & Bennitt, 1999; Torrance & Elley 1998a). Observe the colour and smell of the fresh sample of urine and note any abnormalities in the patient/client s documentation (Anonymous, 1999; Cook, 1996; Torrance & Elley 199a). Always follow the manufacturers instructions regarding use and storage of reagent strips and ensure proper time is allocated before recording results (Anonymous, 1999; Halloran & Bennitt, 1999; Torrance & Elley 1998b;Mallett & Dougherty 2000). The strips should always be stored in the bottle containing desiccant, with the lid firmly secured and away from direct sunlight (Cook, 1996; Halloran & Bennitt, 1999). Check the expiry date on the bottle (Cook, 1996). Dip the strip into the urine so that all of the pads are immersed and come into contact with the urine then remove immediately (Mallett & Dougherty 2000; Torrance 1998b; Anonymous 1999; Bayer 1998). Remove any excess urine by wiping the back of the strip along the rim of the container. Excess urine can wash the chemicals from the pads, interfere with surrounding test pads and contaminate the specimen (Rattersbury & Allen, 1987; Mallett & Dougherty 2000, Bayer 1998) Lay the strip on a flat dry surface or hold the strip horizontally to prevent the urine from the pads from mixing together (Anonymous 1999; Torrance 1998b; Mallett & Dougherty 2000). 124

127 Compare the colour of the individual pads on the strip with the colour chart provided on the side of the bottle, once the recommended time has elapsed, usually 60 seconds (Mallett & Dougherty 2000). Any colour changes appearing along the edges of the test areas, or developing after more than 2 minutes, do not have any diagnostic significance (Roche 2001) The result of each test should be accurately recorded in the appropriate patient documentation and abnormalities reported to the appropriate person. Dispose of the urine in a toilet or sluice once testing is complete unless the specimen needs to be sent to the laboratory for further testing (Anonymous, 1999; Torrance & Elley 1998b) Diagnosis or treatment will never be based on one test result alone but will be established as a result of clinical examination and other investigations. False results can be obtained from urinalysis. For instance in women the test for blood may be falsified from three days before to three days after a menstrual period. This is not an erroneous result but a false positive result. It is not, therefore, advisable to perform the test during this time. In addition, after physical activity e.g. strenuous jogging raised values for erythrocytes and protein may occur without being signs of disease (Roche 2001). Specimen Collection Clean Specimen of Urine A clean urine specimen can be used for a routine urinalysis but is not clean enough for laboratory investigation. To obtain a clean specimen, the patient/client is asked to pass urine into a clean receptacle, such as a disposable bedpan or urinal. Early morning Urine (EMU) The first sample of urine voided each day is usually the most concentrated and so is the preferred specimen when testing, particularly for substances that may be present in low concentration such as hormones in a pregnancy test. Midstream Specimen of Urine (MSU) Mid-stream urine specimens are required when a more detailed analysis of the urine is required, than can be achieved with reagent strip analysis alone and with the least risk of contamination, usually when infection is suspected. It is the most effective method of obtaining a voided specimen of urine for laboratory analysis (see example microscopy form that is completed and sent to the laboratory with the sample).? Use a sterile specimen container? Explain and discuss the procedure with the patient to ensure understanding of the procedure and consent? Ask the patient to carefully clean the labia or glans with soap and water (not antiseptic) to reduce the contamination from surrounding tissues. Antiseptics can influence the result of the urinalysis (Mims et al, 1993 cited in Mallett & Dougherty, 2000)? Allow the first part of the urine stream to be voided and then catch the rest this helps to wash out any contaminants that may be present in the urethra 125

128 Catheter Specimen of Urine (CSU) A CSU is taken using a non-touch technique by obtaining a sample of urine through the specimen portal in the catheter bag tubing using a needle and syringe. The specimen portal should be cleaned with an alcohol wipe and allowed to dry. The sterile needed (21 gauge) is then inserted into the portal and approximately millilitres of urine is withdrawn into the syringe. The specimen is then transferred to a specimen container. It may be necessary to clamp the catheter tubing below the level of the catheter portal for approximately one hour prior to taking the sample if no urine can be obtained. Urine should not be sampled from the catheter bag itself as it is not freshly voided urine and may be contaminated. 24 Hour Urine Collection A 24 hour urine collection is sometimes required to assess the amount of a substance that is excreted in the urine. All urine must be collected during this time, if some urine is disposed of accidentally it may be necessary to commence the collection again, although sometimes this may not be necessary but the laboratory should be informed that the urine collection is not complete. For some collections, a preservative may be required in the collection bottle, for example a creatinine clearance test, which may be required to assess the stage renal disease. All specimens should be clearly labelled and sent immediately to the laboratory upon completion delay allows the specimen to deteriorate leading to inaccurate results. ACTIVITY: Please answer the following questions: From your observation of the colour and odour of urine, what might lead you to suspect that a urinalysis test is needed? Do you need to wear sterile gloves when carrying out a routine urinalysis test? Why do you need to wear gloves? Identify five sources of error when carrying out a urinalysis test: What does NAD stand for? If you obtain a positive result following a urinalysis test, how and where do you record it? Give an example from practice when you might need to take one of the following urine specimens: Clean Specimen of Urine EMU MSU CSU 24 hour urine collection 126

129 Laboratory Analysis of Urine Samples Due to her immunosuppression, Margaret is at an increased risk of infection. The doctor asks for a clean-catch, midstream urine sample. This was collected and sent to microbiology. A number of other patients from the ward have also provided routine urine samples for analysis. The details of these patients are provided below and their urinalysis results are provided on the next page. Using the urinalysis data sheet your task is to determine which sample belongs to which patient. You should note all of the signs that lead you to your conclusions some are obvious but some are more subtle. Explain where possible how the normal physiological function was affected by each of the conditions of these patients. Mrs Pickles - has been admitted for tests. She has hypertension (high blood pressure), oedema and has recently been suffering from difficulty in breathing and headaches. She was found to have a kidney condition called glomerulonephritis. Mr Swift - collapsed after running a marathon. The day had been quite warm and worried about falling behind the leaders, Mr Swift had been reluctant to stop for water during the race. After rehydration and observation, he was discharged. Mrs Trinder - had been ill for some time. She was known to be suffering from diabetes mellitus and her consultant was concerned about developing signs of nephritis. She has hypertension, which may be related to her obesity that had worsened recently and was being kept in for further tests. Mr Toper well known to the police, had been brought in by after being found unconscious in a doorway. He had drunk a large amount of beer and had passed out from its effects. After 24 hr observation, he was discharged. Mr Steptoe - was an elderly gentleman living on his own. Social Services were concerned that he was not looking after himself particularly as he had recently complaining about feeling under the weather. After collapsing in the street, he was admitted to hospital in an emaciated state. Ms Green - is four months pregnant and apart from recurrent cystitis, is otherwise well. She is very health conscious, takes regular exercise and is a strict vegetarian. She had only come to hospital for amniocentesis when she complained of abdominal pains and feeling faint. She was admitted for observation but tests proved negative and she was discharged the following morning. 127

130 Results Sheet from Pathology Lab. Sample A Sample B Sample C Sample D Sample E Sample F Colour Dark straw Straw hazy Light straw Dark straw Straw hazy straw Volume (ml/24hr) Glucose (mmol/l) neg trace (5.5) neg neg neg Bilirubin (µmol/l) neg neg positive (20) neg neg neg Ketones (mmol/l) moderate neg neg neg small neg Specific gravity Erythrocytes (RBC/dL) neg ++ moderate neg haemolysed trace ++ moderate neg ph Protein (g/l) neg trace neg Urobilinogen (EU/dL) positive 3.2 positive Nitrite (µmol/l) Urine Culture neg neg neg neg neg positive neg neg neg neg neg positive leucocytes (cells/µl) neg trace neg neg neg ++ moderate 128

131 Laboratory Analysis of Urine Samples Data Sheet The first part of a urinalysis is direct visual observation. Normal, fresh urine is pale to mid straw in colour and clear. Typical urine volume is 1000 to 2000 ml/24hr. Turbidity or cloudiness may be caused by excessive cellular material or protein in the urine or the presence of haemoglobin. Glucose - less than 0.1% of glucose normally filtered by the glomerulus appears in urine. Glycosuria (excess sugar in urine) generally indicates diabetes mellitus. Bilirubin is produced when the liver breaks down old erythrocytes. It is excreted via the bile duct into the duodenum and does not appear in the urine unless the liver is damaged by cirrhosis etc. Ketones (acetone, aceotacetic acid, beta-hydroxybutyric acid) occur in the urine because of either diabetic ketosis or some other form of calorie deprivation. Specific gravity is directly proportional to urine osmolarity and is a measure of urine density, or the ability of the kidney to concentrate or dilute the urine over that of plasma. Typical specific gravity of urine from the normal kidney lies between and Dehydration will increase specific gravity, as will protein and glucose in the urine. Blood - haematuria is the presence of abnormal numbers of red cells in urine due to: glomerular damage, tumors of the urinary tract, kidney trauma, urinary tract stones, upper and lower urinary tract infections and physical stress such as endurance sports. Red cells may also contaminate the urine from the vagina in menstruating women or from trauma produced by bladder catheterisation. Urinary ph is typically on the acid side of neutral, around ph 6.0. Diet affects the ph of urine, especially meat that increases its acidity. Protein - normal total protein excretion does not usually exceed 150 mg/24 hours or 10mg/100ml in any single specimen. More than 150mg/day is defined as proteinuria. Protein excretion can be elevated by nephritis, cirrhosis, excessive exercise and pregnancy. Urobilinogen is produced in the intestine from bilirubin and is normally excreted although some is recycled and appears in the bloodstream. Typically, urine levels are negligible so high levels of urobilinogen indicate liver damage or a high turnover of erythrocytes. Nitrite Bacteria convert nitrate NO 3 - into nitrite NO 2 so a positive nitrite reading indicates that bacteria may be present in significant numbers. Gram-negative rods such as E. coli are most likely to give a positive test. Leucocytes - a positive leucocyte esterase test means that leucocytes are present in the urine and that an infection of the urinary tract is likely. This can be confirmed and specified by microscopic examination and/or urine culture. 129

132 Urinalysis and Diabetes Urinalysis and Diabetes The Pancreas By the end of this session you should be able to:- Outline normal glucose control Define the 2 different types of diabetes Know why glucose appears in the urine in diabetic patients Know the basic symptoms of diabetes Islets of Langerhans The normal pancreas has about I million islets cells The main cells types are: Alpha:- produce glucagon Beta:- produce insulin Delta Control of glucose Normal blood glucose should ideally be between 4-7 mmol/l Insulin is secreted from beta cells in the pancreas as a response to an increase in blood glucose (BG) concentration Insulin is the only hormone that can lower BG Glucagon acts antagonistically to insulin and serves to increase BG levels Glucagon is stimulated by a decrease in BG concentration below normal levels Control of glucose Diabetes Mellitus Diabetes: from the Greek, meaning to run through a siphon Mellitus: from the Latin word for honey Two main types of diabetes mellitus Type 1 Type 2 Hypoglycaemia low blood sugar Hyperglycaemia high blood sugar 130

133 Type 1 Diabetes Formally called insulin dependent diabetes or juvenile Characterised by beta cell destruction usually caused by an autoimmune process Usually leads to absolute insulin deficiency Type 2 Diabetes Formally called non-insulin dependent diabetes Characterised by a combination of resistance to insulin action in peripheral tissue and an inadequate compensatory insulin secretary response by insulin secretary defect of the beta cell Cell Biology of Insulin Response Normal Cell Cell Biology of Insulin Response Type 1 Diabetes Cell Biology of Insulin Response Type 2 Diabetes Glucose in the Urine When BG rises above 10 mmol/l, the kidney can not reabsorb all of the glucose found in the blood. The excess glucose appears in the urine Glucose attracts water in the bladder and produces large amounts of dilute urine. One of the symptoms of diabetes is increased volume and frequency of urination. Other symptoms include fatigue, as glucose is needed for cell respiration to make energy. They also feel thirsty as water is lost from increased urination 131

134 References and Further Reading Anonymous (1999) Urine Testing, Quick Reference Guide 8. Nursing Standard 13 (50) insert 2p Bayer (1998) A Practical Guide To Urine Analysis. Bayer, Newbury Clarke, M. (1991) Practical Nursing, Hospital and Community Nursing and Health Perspectives, 14 th Ed. Balliere Tindall: London Cook R (1996) Urinalysis: ensuring accurate urine testing. Nursing Standard 10, 46, Halloran S & Bennitt W (1999) Urine Reagent Strips : an MDA Evaluation. Professional Nurse 14 (11) Kenworthy, N. Snowley, G. & Gilling, C. (1996) Common Foundation Studies in Nursing. 2 nd Ed. Churchill Livingstone: Edinburgh Mallett J & Dougherty L (2000) (Ed) Manual Of Clinical Nursing Procedures 5 th Ed. Blackwell Science, Oxford Marjoram B (2002) Elimination Chapter 5 pg In: Hogston R & Simpson P M (Ed) Foundations of Nursing Practice Making the Difference. Palgrave MacMillan, Hampshire. Nursing Times (2002) Diagnostic procedures London, Emap Healthcare Ltd Ratterbury J M & Allen J C (1987) Sample Contamination By Strips. Clinical Chemistry, 33, 414 Roche Diagnostics Ltd. (2001) Instructions for the use of the Combur 5 Test (Pack insert) Torrance C & Elley K (1998) Practical Procedures For Nurses. Urine Testing 1 Urinalysis No 7.1 Nursing Times 94 (4) insert 2p Torrance C & Elley K (1998) Practical Procedures For Nurses. Urine Testing - 2 Urinalysis No 7.2 Nursing Times 94 (5) insert 2p 132

135 Section 6: Introduction Three months after discharge from hospital Margaret feels very down, she is unable to sleep and is tearful. Her GP suspects that Margaret is depressed. If Margaret had a learning disability Specialist assessment forms could be used by the CLDT member to check for depression (i.e. mini PASSAD) or a referral may be made to the psychiatrist who is a member of the CLDT. If appropriate, Margaret may also be referred to see the psychologist to talk about her illness. In this section you will consider the basic issues relating to the administration of medication, physiology of drug absorption and elimination, depression and physiology related to synapses and neurotransmitters. 133

136 Session 20: Drug Administration Useful Link: UCE MOODLE Since her diagnosis, Margaret has been prescribed a number of different drugs. What types of drugs may Margaret have taken? Name some drugs that you are familiar with? In this tutorial we will look at different ways that drugs may be taken, and what happens to them in the body. What is a drug? Biological factors affecting the action of drugs A drug is something that exerts a chemical influence on a cell, resulting in a pharmacological response. Small molecules are introduced into or applied onto the body that induce various effects, amongst which is the desired therapeutic effect. How do drugs work? Most drugs bind to proteins in the body such as receptors on cells or enzymes Drug Receptor Cell drug enzyme Drug binds to receptors on cells and produces effect on tissue example β-blockers Drug blocks active site on enzyme and prevents it performing its task example - Statins The three main stages in the physiological handling of a drug Absorption: entrance into the blood stream (most drugs). Distribution: movement of drug to various parts of the body Elimination: metabolism (breaking down) and excretion Absorption The route of administration may affect how quickly the drug is absorbed. Intravenous drugs will reach their target rapidly however, local administration can also be very effective, e.g. inhalation of bronchodilators. Drugs administered via intra-muscular or subcutaneous routes can take longer to be absorbed. Drugs administered orally must pass through the GI tract before they enter the blood stream. First-Pass Metabolism Drugs that are absorbed from the gut are first metabolised by the liver. This is called first-pass metabolism. Many drugs cannot be administered orally because the liver breaks them down e.g. GTN. Some drugs are activated by the liver e.g. Aspirin 134

137 Drug absorption from the GI tract Mouth Stomach Small intestine Large intestine General circulation Liver Factors affecting drug absorption In addition to the site of administration, the efficacy of drug absorption is also affected by many other factors. Presence of digestive enzymes Stomach acid Presence of food GI motility Blood supply / blood pressure Rectum General circulation Question. Amarjeet is a 13-year old female who has type I diabetes mellitus.she routinely administers insulin via subcutaneous injection. Why is insulin given by injection rather than tablets? Distribution Once a drug has entered the circulatory system it must be delivered to its target in order to exert an effect. A well functioning cardiovascular system optimises delivery. Generally, drugs travel bound to plasma proteins that are made by the liver. Movement of the drug around the body Brain Muscles Heart Physiological factors affecting drug distribution Liver Kidneys Blood Fat Skin Bone Plasma protein levels (reduced in liver disease) Blood flow (may be compromised in CHF congestive heart failure) Question. Mary is a 32-year old female who is 8 months pregnant. Why could drugs be dangerous in the pre-natal and post-natal periods? 135

138 Elimination Generally subdivided into: Metabolism: The chemical alteration and breakdown of the drug into metabolites, performed by the liver. Excretion: Removal of drug or metabolites from the body, usually in the urine. Excretion Drugs can be excreted in all body fluids: urine, saliva, sweat, breast milk The urinary system is the principal route for drug excretion Unless excreted or metabolised, drugs would remain in the body indefinitely and reach potentially harmful levels. As drugs are continually broken down and removed from the body, they need to replaced to maintain a constant, therapeutic level in the blood. The Bath Theory Constant drug metabolism and elimination Regular drug administration Constant, therapeutic level of circulating drug Drug Interactions Different drugs can compete and bind to similar receptors. Drug action can be reduced and side effects can be increased by interactions. Consideration of drug interactions is important, especially in the elderly where poly-pharmacy is common. Case study: Harold is a 78-year old male who has been admitted to hospital with congestive heart failure (CHF) which has resulted in liver and kidney damage. He is presently taking digoxin to manage his condition. How may his liver and kidney problems affect the distribution and elimination of his medication? Case study: Margaret has been prescribed Amitriptyline. She has to take her medication 3 times a day. Why are many drugs taken several times a day rather than daily, or weekly? Margaret s medication is in tablet form. Suggest some factors in her life that may affect the efficiency of this regime. 136

139 Drug Administration: To give a medicine either by introduction into the body, whether by direct contact with the body or not (e.g. orally or by injection) or by external application (e.g. application of an impregnated dressing) Section 130, Medicines Act Drugs can be administered for the following reasons: Diagnostic purposes, e.g. assessment of liver function. Prophylaxis, e.g. heparin to prevent thrombosis. Therapeutic purposes, e.g. replacement of fluids, antibiotics for infection, anti-emetics for nausea & vomiting. Different name, same drug: Medicines may have several different names for instance: Chemical * Acetylsalicylic Acid Approved * Aspirin Proprietary * Caprin Dosages: Nanograms written in full Micrograms written in full Milligrams mg Grams g Millilitres ml International Units iu Mass Volume 1 kilogram (kg) = 1000 grams (g) 1litre = 1000 millilitres 1gram (g) = 1000 milligrams (mg) 1 millilitre = 1000 microlitres 1 milligram = 1000 micrograms 1 pint = 568 ml 1 microgram = 1000 nanograms 1nanograms = 1000 picograms Routes of administration: Internally: Orally Sublingual Buccal Injections Subcutaneous Intradermal Intramuscular Intravenous Intrathecal Other internal Rectal Vaginal Eye / ear drops 137

140 Externally Ointments Creams Lotions Oils Transdermal patch Controlled Drugs (C.D s) CD s are governed by the Misuse of Drugs Act 1985 and are described as natural opiates & their synthetic substitutes. Opiates are a group of drugs derived from opium and include morphine; it s synthetic derivative diamorphine, codeine and papaverine. Opiates depress the central nervous system: they relieve pain, suppress coughing and stimulate vomiting. (Stimulants including amphetamine & cocaine and hallucinogens i.e. LSD & cannabis are also controlled drugs) In Hospital: CD s must always be given by two people. A CD book must be kept on the ward. Both nurses must sign the book following each administration. The prescription should show the dose in words and figures. The CD book must be kept on the ward for 2 years after the date of the last entry. The CD s must be kept inside a locked cupboard that is inside a second locked cupboard & the keys retained by a Registered Nurse. Principles for the Administration of Medicine: Before you give any medicine the nurse should: Know the therapeutic use, normal dosage, side effects, precautions & contra-indications (it is not possible to remember every drug that you may come across BUT you must know where & how to find this information before you give any drug that you don t know) Be certain of the identity of the patient. Be aware of the patient s care plan and current treatment. Check that the prescription or medicine label is clearly written & unambiguous. Check that the drug has been stored correctly & check it s expiry date. Check if the patient has any allergies. Consider the dosage, method of administration, route & timing in the context of the condition of the patient & co-existing therapies. Contact the prescriber where contra-indications are discovered, where reactions occur or where assessment indicates that the drug is no longer suitable. Document all drugs administered, intentionally withheld or refused. A registered nurse MUST countersign student signatures. (NMC 2002) Remember the Five Rights Correctly administer The RIGHT drug in the RIGHT dose via the RIGHT route at the RIGHT time to the RIGHT patient 138

141 As a Student: It is your responsibility to ensure that you acquire the necessary knowledge to administer medication independently as a Registered Nurse When administering medication you must follow the NMC Guidelines for practice, hospital policies and be directly supervised at all times. In the event of a medication error the nurse should: Monitor the patient / client for any side effects & inform them what has happened. Report the incident immediately to the nurse in charge & the doctor. Preventative measures may be taken to control the effects of the drug(s) An incident form must be completed. AS A STUDENT NEVER ADMINISTER ANY MEDICATION WITHOUT THE DIRECT SUPERVISION OF A REGISTERED NURSE. Activity: What does a doctor have to do prior to writing a prescription? What information is included in the prescription? Using the resources provided answer the following: Margaret goes to see her GP as she feels very weepy, cannot sleep & has lost her appetite; her doctor prescribes Amitriptyline 25mgs three times a day. What type of drug is this? What side effects would Margaret be warned about and what other important information must Margaret be given? Liam an eight-year-old child in your care has been prescribed Paracetamol 500mg tablets but has problems swallowing the tablets, what can you do? Narinder complains of a migraine with nausea and can t take her Imigran tablets, as she will be sick, how else could she take it? What is Imigran s chemical name? A patient is brought into A & E having taken an overdose of Paraquat, where can you find information on what to do? You are looking after Millie, a terminally ill patent and she has excessive respiratory secretions, the family finds the rattling noise when she breathes distressing. What can you give to help relieve this? Harry has had a long history of depressive illness and had recently been started on Prozac by his doctor. He has been admitted after expressing suicidal thoughts. What is Prozac s chemical name? Are Harry s suicidal thoughts the result of his illness worsening or could there be another reason? How do you report suspected adverse reactions? You are looking after Bob who has been taking Amiodarone 200mg OD to control his cardiac arrhythmia with success for a number of years. He suddenly develops Atrial Fibrillation (AF) shortly after commencing co-trimoxazole for a urinary tract infection. You suspect that there may be a drug interaction how do you find out? 139

142 Self Directed Activity (4 hours approx) Useful resource: Read Chapters 1 & 2 Illustrated Pharmacology for Nurses available in the library. The strength of tablets, capsules or injections you have available doesn t always correspond to the required dose. Therefore you often find you are required to calculate the number/volume needed. As a student nurse you are expected to develop this skill always working under the supervision of a qualified nurse, the following activities are designed to help develop the skill. Undertake the following calculations of drug dosages to assess your ability and need for further support with drug calculation mathematics (answers at back of work book). Visit the skillswebb page, click on useful links and visit the drug calculations for nurses website. Practice drug calculations and test yourself Read and undertake the practice calculations from Lapham and Agar (essential reading list) chapter 1 and 2. Drug Calculations 0 Dose prescribed, diazepam 15 mg. You have 5 mg tablets available how many do you give? 1 Dose = 8 mg/kg, the patients weight is 64.5 kg. How much do you give? 2 How many millilitres per hour would need to be administered for 1 litre of glucose 5% to be infused in 6 hours using a standard giving set? 3 Dose prescribed 250 mg intra muscular injection. Available is 500mg in 2 ml. How much do you give? 4 A 3 year old child weighing 13.5 kg is prescribed Ibuprofen at a dose of 5 mg/kg. Ibuprofen is available at 100mg in 5 ml. How much do you give? Useful resource: 140

143 Session 21: Depression Link Session Self-Directed Activity: Please read through the following material and complete the questions before coming to the session. Three months after discharge from hospital Margaret feels very down, she is unable to sleep and is tearful. Her GP suspects that Margaret is depressed. Depression may be caused by an imbalance of neurotransmitters in the brain. In order to prepare for the physiology link session on depression you will need to do some pre-reading on the nervous system. Refer to a physiology textbook and look up the relevant chapter on the nervous system. You may also want to refer to an excellent journal article on this topic Blows W (2000) Nervous System 1. Nursing Times, vol 96, No35. You can find this article in the reference library. References: Blows W (2000) Nervous System 1. Nursing Times, vol 96, No35. Marieb, E (2000) Essentials of Human Anatomy and Physiology. Addison. Vewtech. The human body series: The Nervous System. Uniview Worldwide Ltd. Now try to answer the following questions: 1. The nervous system is divided into the central nervous system and peripheral nervous system. a. The CENTRAL nervous system consists of the and. b. The PERIPHERAL nervous system consists of A nerve is a collection of nerve cells (neurons), often many thousands, encased in a fibrous sheath. Neurons or nerve cells convey information within the nervous system. Neurons come in a variety of shapes and sizes but all have the same basic structure. Some neurons, travelling from the extremities to the CNS can be over one metre long! The nervous impulse itself is quite complicated but can be thought of as a small ripple of electrical activity. Label the diagram of a neuron on the next page. a. What is a neurotransmitter? b. The two neurotransmitters associated with depression are Noradrenaline and Serotonin. Can you name TWO other neurotransmitters found in the body. 4. Neurotransmitters act at the synapse and this is also where many drugs such as antidepressants act. What is a synapse and where are they found? 141

144 5. Fill in the following table: LOBE FUNCTION Frontal Occiptal Sensory perception and language interpretation Hearing and emotions Typical Neuron Cell Body 2. Dendrites 3. Axon Hillock 4. Terminal Buttons 5. Axon terminal 6. Axon 7. Nodes of Ranvier 8. Schwann Cells

145 Module GM4078 Core Skills and their Theoretical Framework Link session on Depression Learning objectives By the end of today s session, you should be able to: 1. Identify a range of signs associated with depression 2. Outline the biological theories of depression 3. Recall the main groups of antidepressant drugs and the physiological basis of their action. 4. Discuss examples of antidepressants and common side-effects. Case Study Three months after discharge, Margaret visits her GP for a routine check up. The GP notes that Margaret has had difficulty sleeping and appears a little tearful at times. She has lost her appetite recently and has lost some weight. The GP thinks that Margaret might be depressed. Case study questions What signs and symptoms, associated with depression does Margaret display. Can you think of any other symptoms that are associated with depression Do you know of any types of depression? Have you come across any side effects of patients on anti-depressants? If so what were the side effects? Signs and symptoms of depression Depression manifests in a combination of symptoms (that interfere with work, study, eat and sleep) resulting in a profound and constant sense of hopelessness and despair. This may occur once but more commonly occurs several times in a lifetime. Signs and symptoms of depression Poor appetite & weight loss or Increased appetite & weight gain Sleep disturbance Loss of libido Guilt Worthlessness Panic attacks / palpitations Depressed mood Anxiety Agitation Changes in mood/fluctuations Loss of pleasure Loss of energy Obsessive-compulsions 143

146 Types of depression Psychotic depression Hallucinations, paranoia & delusions Clinical / unipolar depression Requires treatment Manic / bipolar depression Up and down mood rollercoaster Post-natal depression Usually disappears after a few weeks Post-partum depression More serious mood changes lasting months Post partum psychosis more severe still - violent Biological Basis of Depression Depression may involve an imbalance of chemical messengers in the brain called neurotransmitters Let s look more closely at the nervous system and chemical transmission A Neurone Basic cell of nervous system Neurones conduct dendrites electrical impulses allowing communication between cells nodes of Ranvier Schwann cells cell body - soma axon hillock axon re-uptake transporter Action at the synapse Neurones do not make direct contact with each other a small gap called a synapse exists, across which the signal must pass neuron terminal neurotransmitter post-synaptic membrane direction of nervous impulse axon terminals receptors ion channel A theory of depression Depression is caused by a reduced activity of some neurotransmitters For example, serotonin, noradrenaline and dopamine Structures of brain associated with depression Low activity of these neurotransmitters may contribute to reduced stimulation of particular areas of the brain that results in a depressed mood: Frontal and temporal lobes, limbic system and brain stem The hypothalamus and pituitary gland may be involved 144

147 Evolving views of depression Hormonal Depression results from prolonged stress Perhaps due to increased levels of stress hormones Genetic / environmental Propensity to develop depression but an external trigger needed to elicit the manifestation Antidepressant Groups SSRI = Selective Serotonin reuptake inhibitor SNRI = serotonin and Noradrernaline reuptake inhibitor TCAs = Tricyclic antidepressants MAOI= Monoamine oxidase inhibitor NaSSA= Noradrenergic and specific serotonergic Some Common Antidepressants Generic name Fluoxetine Dosulepin Hydrochloride Manurfacturer s name Prozac Prothiaden Group SSRI TCA re-uptake transporter Action of common antidepressants nervous impulse neuron terminal neurotransmitter Venlaflaxine Efexor SNRI TCAs, SSRIs & SNRIs post-synaptic membrane receptors ion channel Mechanisms of Action of common antidepressants Reuptake of a neurotransmitter is blocked SSRIs (block serotonin reuptake) SNRIs (block noradrenaline and serotonin reuptake more specific than TCA) Effect Drugs inhibit the reuptake of the neurotransmitter into presynaptic terminal Increases time/ concentration that the neurotransmitter is active in synapse Results in increased activity of the neurotransmitter = improved mood Some side effects of antidepressants Nausea initially Dry mouth Constipation Headache Sleep disturbance Sexual dysfunction Weight gain Increased aggression/suicidal behaviour (SSRI) 145

148 Non Pharmacological interventions Talking therapies (CBT, brief therapy) Electro convulsive therapy Exercise Light treatment Herbal (St Johns wort) Reference List Shupikai Rinomhota, A. & Marshall, P. (2004) Biological Aspects of Mental Health Nursing. Churchill Livingstone Pinel,J.P. (2005) Biopsychology. Allyn and Bacon Widmaier E. P, Raff H, Strang K. T (2004). Vander, Sherman & Luciano's Human Physiology. The mechanisms of Body Function. p BNF 2005 for list of antidepressants. A useful website called 146

149 Session 22: Health Assessment Link Session The aims of this session are; To review work covered on the circulatory and respiratory systems prior to your exam. To link your knowledge of physiology to patient assessment prior to your first placement experience. Before you attend this link session you should; 1. Review the work covered on circulation and respiration previously in the module, 2. Read chapters on respiratory and circulatory system in a physiology text book from your reading list such as; Marieb (2005) Essentials of Anatomy and Physiology.Pearson. 3. Use your revision and reading to answer the following questions. Bring your answers to the link session. QUESTIONS 1. What are the differences between the structure and function of arteries and veins? 2. Distinguich between the systemic and pulmonary circuit. 3. Do all arteries carry oxygenated blood? 4. Is pulse rate a measure of blood pressure or heart rate? 5. What is blood pressure? 6. Which pressure is higher, systolic or diastolic? 7. If a patient has a bleed, what are the likely effects on her; a) blood volume, stroke volume and cardiac output at first? b) heart rate and peripheral blood flow as the body compensates. 8. Why might an anxious patient have cool and clammy skin? 147

150 Linked Physiology: Patient Assessment By the end of the session you should be able to: List the ways in which nurses can assess the circulatory and respiratory function of patients. Explain the significance of both quantitative and qualitative information produced by different methods of patient assessment. List examples of common problems affecting respiratory function and explain how these affect respiratory physiology Explain the significance of changes in blood pressure and pulse rate readings. Circulation revision 1. What are the differences between the structure and function of arteries and veins? 2. Distinguish between the systemic and pulmonary circuit. Circulation revision 5. What is blood pressure? 6. Which pressure is higher, systolic or diastolic? 7. If a patient has a bleed, what are the likely effects on; a) blood volume, stroke volume and cardiac output at first? 3. Do all arteries carry oxygenated blood? b) heart rate and peripheral blood flow as the body compensates. 4. Is pulse rate a measure of blood pressure or heart rate? 8. Why might an anxious patient have cool and clammy skin? Respiratory System Flow chart Drive from CNS Neuromuscular function Mechanics of chest wall and lung movements Pressure changes in lungs Ventilation Gas transfer Carriage in bloodstream Group work- conditions affecting the respiratory system In groups, identify examples of diseases/ conditions that would affect each stage of the flowchart. Transfer to tissue cell Use in tissue cell energy 148

151 Methods of patient assessment Patient assessment methods You are a student on placement, how would you assess the respiratory and circulatory function of a patient in your care? In groups, list as many assessment methods as you can. Quantitative and Qualitative assessment Quantitative assessment Qualitative assessment Case study 1- Leah Leah, 8, has been brought in to A&E by her parents. She has asthma, and has had a bad cold for a week. Since the previous night her breathing has deteriorated despite using her inhalers. What is asthma and how does it affect her breathing? (refer to the flow chart). Explain how her cold has worsened her condition. What is the function of her inhalers? Leah s Admission When Leah arrived she was wheezy, cyanosed and couldn t talk properly. Her respiration rate was 35/min, and her O 2 saturations were 84%. Leah s heart rate was 115 bpm. Why had her respiratory rate increased to 35/min? What is normal? How is respiration rate controlled? Why were her saturations only 84% (refer to the alveoli) What is normal? Why is she wheezy? Why is she cyanosed? Comment on Leah s heart rate. Control of respiration respiratory centres in medulla phrenic nerve to diaphragm brain diaphragm chemoreceptors on aorta and carotid artery heart intercostal nerve to external intercostal muscles ribs 149

152 PCO2 in arterial blood PCO2 in arterial blood expiration of PCO2 rate and depth of ventilation Response to hypercapnia more CO2 crosses blood brain barrier PCO2 in CSF H + in CSF stimulation of central chemoreceptors frequency of impulses to medullary rhythm generator Leah s Treatment Leah was given oxygen at 2-4 L/min and a nebuliser of salbutamol and atrovent. Her breathing improved but she was still wheezy. Her nurse talked to Leah and was able to reassure her, Leah was able to play with other children on the ward. She was given a second nebuliser, but was still wheezy. Peak flow readings were taken 4 hourly and they increased from 180 to 230 L/min. The next day she improved and was commenced on antibiotics. Regular nebulisers and oxygen were prescribed. After a few days she was discharged home Leah s Treatment- questions Why was she given antibiotics? What is peak flow a measure of? Why wasn t peak flow taken on admission? Explain why her peak flow has changed from 180 to 230L/min. How would reassurance and distraction aid Leah s recovery. If Leah had learning difficulties, how may this influence her care needs? Case study 2- John s history John is 63 and has attended casualty following a collapse at home, No obvious injuries noted. John remembers standing to answer the phone, but then passed out. John is currently taking haloperidol as he has mental health problems, but is otherwise well. John- assessment Sitting- BP 115/75 mmhg, pulse 75 bpm. Standing- BP 95/60 mmhg, pulse 92 bpm. Respiration rate- 22 breaths per minute, shallow. Temperature C Where would you take John s pulse? What factors would you assess? Can you explain John s results? How might this account for his collapse? You should now be able to: List the ways in which nurses can assess the circulatory and respiratory function of patients. Explain the significance of both quantitative and qualitative information produced by different methods of patient assessment. List examples of common problems affecting respiratory function and explain how these affect respiratory physiology Explain the significance of changes in blood pressure and pulse rate readings. 150

153 Session 23: Exam Preparation and Module Evaluation In this session we will confirm all the arrangements for your examination including date, time, room, areas to revise. We will also discuss revision tips and go over the format of the exam. You have been provided with a past paper at the back of the workbook. You should attempt this before the exam preparation session and bring your answers with you. Other Associated Skills Sessions: Alongside the tutorial sessions, students will also have practical sessions relating to basic life support & manual handling (compulsory) injections, communication skills, observations, optional hygiene & skills practice. Please remember you will NOT be allowed out on placement if you have not completed the Manual Handling skills session or Basic Life Support skills session. You will not be allowed into these sessions if you turn up late. In this section you will find handouts relating to the skills sessions if they have not already appeared in the workbook i.e. Injections technique, Basic Life Support & oral hygiene. Drug Calculations Answers (Session 20) 1. 3 tablets 3 x 5 = 15 mg mg 8 x 64.5 = 516 mg millilitres per hour 4. 1ml (250 mg / ml) ml 5x 13.5 = 67.5mg (dose that needs to be given) 100mg in 5 ml of Ibuprofen (available) 67.5 mg = 5 x 67.5 = ml 100 Further help with drug calculations is available from the Personal Development Centre at UCE Tel

154 APPENDIX ONE Cardio-Pulmonary Resuscitation (CPR) Complete this gapped handout with reference to guidelines from the Resuscitation Council (UK) web-site (www.resus.org.uk). Some items will need to be completed when you go on your first placement. 1. Define the term basic life support (BLS): 2. What is the purpose of BLS 3. There are different guidelines for BLS for adults and children. How do the paediatric BLS guidelines define ` a) a child: b) an infant: 4. What symptoms should alert you to the possibility of cardiac arrest? 5. The sequence of actions for both adult and child BLS requires you to ensure the safety of the and the. When you go on your first placement identify common hazards you may find if an emergency arises in that area. 6. How should you check for the response of a) an adult: b) a child: c) an infant: 7. If there is no response guidelines state you should shout for help. Are there any other ways of summoning help in your placement area? 8. How should open the airway of a) an adult b) a child c) an infant 9. How long you should you spend checking for breathing? This time is the same for both adult and paediatric resuscitation. 10. If the victim is not breathing you should send for emergency help. What is the emergency telephone number to dial on your placement? 152

155 Remember this number is not the same for all NHS Trusts, and for placements outside acute hospitals you may need to phone for an ambulance. 11. When rescue breaths are delivered they must be effective. How do you know a rescue breath is effective? 12. State how you would check for a pulse for a) an adult: b) a child: c) an infant: Regardless of age, a pulse check should take no more than. 13. What is the correct ratio of chest compressions for a) an adult? b) a child? c) an infant? 14. When should you commence chest compressions for a) an adult? b) a child? c) an infant? 15. How long should you continue resuscitation? 16. When you go on your first placement identify what emergency equipment is available. Which equipment should be obtained first. Are pocket masks available as an alternative to mouth-to-mouth (nose) ventilation? 17. When should a victim be placed in the recovery position? 18. What is the best place to find up-to-date information about resuscitation? Remember performing basic life support is a skill. As well as gaining the knowledge of procedures identified in this handout you need to practice the skills of assessment, airway maintenance, ventilation and chest compression. You should only practice these skills on a resuscitation manikin. 153

156 APPENDIX TWO. Handout for Injections Aim of the Session The aim of the session is to review the literature in relation to injection techniques, demonstrate these techniques and allow you, the student, to practice the techniques in a safe environment. The skill of giving an injection is not just about the practical aspects but also about communication with the patient/client, reassuring them and providing distraction where appropriate. Full consent must be gained before administering an injection. Q. Under what circumstances might a drug need to be given by injection rather than orally? There are a number of reasons why an injection might be painful: site of injection, type of injection, if the muscle is tense, drug being administered, speed of administration, amount of fluid being administered. The pain can be reduced in a number of ways: Prepare patient Change the needle Position the patient so that the designated muscle group is flexed and therefore relaxed (Swearingen, 1991) If cleaning the skin before needle entry, ensure skin is dry before injecting (Mallett & Dougherty, 2000). Consider using ice, freezing spray or numbing cream to numb the skin before injection, or press firmly on the site for 10 seconds prior to inserting the needle. Pressure has the effect of confusing the pain pathways and can reduce pain (Barnhill et al, 1996; Chung et al, 2002). Use the Z track technique (Beyea & Nicholl 1995; Newton et al, 1992; Workman 1999). Rotate sites so that the left and right sites are used in turn, document rotation Enter the skin firmly with a controlled thrust (Bolander, 1994 cited in Rodger & King, 2000) or using a quick dart-like motion (Craven & Hirle, 1996 cited in Rodger & King, 2000). Inject medication steadily and slowly; about 1 ml per 10 seconds to allow muscle to accommodate the fluid (Farley et al, 1986; Keen, 1990) Some authors (Kozier et al, 1993; Beyea & Nicoll, 1995) recommend that the practitioner should wait for 5-10 seconds after completion of injection, to allow the medication to diffuse, before withdrawing the needle at the same angle as it entered. However, Rodger & King (2000) argue that the amount of absorption and dispersion of the drug that would occur during this time is questionable and that the needle should be withdrawn rapidly after completion of the injection and pressure applied to any bleeding point. Do not massage the site afterwards, but be prepared to apply gentle pressure with a gauze swab (Bolander, 1994 cited in Rodger & King, 2000; McConnell, 1993; Beyea & Nicoll, 1996) Q. There are four types of injections, what are they? 154

157 As a student you should not administer ANY injection without the direct supervision of a registered nurse and the administration of any medication should comply with the Guidelines for the Administration of Medicines, laid down by the NMC (2002). There are three types of needles used for injections: orange, blue and green. Each needle has a specific size printed on the outer packaging. You mainly need to identify which needle is appropriate for which injection and can do this using the colour code if you wish as these are used nationally. The choice of injection type will depend upon the doctor s prescription and the recommended route for the drug prescribed. What are the 5 rights of drug administration? What else do you need to check apart from the 5 rights? During this practical session you will be using Water for Injection, which does not have a dose. Skin Preparation Skin preparation, prior to giving an injection, is not required unless the skin is visibly dirty in which case you would wash it with. Alcohol wipes (sterets) are no longer advocated; they do not reduce the risk of infection and result in thickening of the skin, which will affect the absorption of the drug (Dann, 1969; Koivisto & Felig, 1978, both cited in Workman, 1999). However, patients/clients whose immune system is depleted (for whatever reason) and so can t fight infection may require skin cleansing (Mallet & Dougherty, 2000; Rodger & King, 2000). If skin cleansing is necessary, clean with an alcohol swab for 30 seconds using a circular motion, with friction. Allow to dry for.. seconds (Simmonds, 1983) Subcutaneous Injections Q. Where is the drug administered?... Q. What size needle would you choose? Q. At what angle is the needle inserted?. With subcutaneous injections you need to pinch a skin fold gently to free the adipose tissue from the underlying muscle this ensures that you are giving the medication by the correct route and so is very important (Workman, 1999). Q. Where can you administer a subcutaneous injection? Q. What sort of medications are given by this route?.. Q. Why is absorption by this route slow?. Q. What is the maximum volume that can be inserted using this injection route?. 155

158 Intramuscular Injections Q. Into which tissue is the drug administered?.. Q. How does the absorption rate from the muscle compare to the subcutaneous tissue?.. Q. What size/colour needle should you use?.. The amount of needle that is left exposed during the injection will depend upon the needle size used and the size of the person. Workman (1999) recommends leaving one quarter of the needle exposed, Jamieson et al (1997) recommends one third so that if the needle breaks it can be removed easily. One quarter of a 21 gauge green needle would be 1cm but you need to ensure that the needle has been inserted into the muscle tissue. A thin person, using a green needle may need 1 1.5cm exposed to ensure that the drug is administered by the right route but in an obese person the amount of needle exposed may be less. The technique used to administer the injection will also be a factor to consider. There is no evidence of needles breaking during intramuscular injections. Q. At what angle is the needle inserted?. If blood is drawn back into the syringe there are two options, depending upon the advice of your assessor. The first option is to take the needle out, dispose of the needle, syringe and its contents and start again but obviously this means that the patient/client has to have two injections. The second option is to withdraw the needle a few millimeters, try to draw back again and if you are not in a blood vessel you can give the injection provided that the needle tip is still in the muscle layer. However, if there is too much blood in the syringe, inserting this blood into the muscle may result in a haematoma and possibly infection. In terms of cross-infection, the patient s own blood won t give them anything that they haven t already got. The decision about which choice to make will depend upon the amount of blood in the syringe, the patient s choice and the advice of the student s assessor, there is no definitive evidence to support either choice although Mallett and Dougherty (2000) recommend the first option. There are three main techniques for giving an IM injection: 1. bunching the muscle mass together, particularly in children or adults who are very emaciated, but don t pinch the subcutaneous tissue away from the muscle. 2. Stretching the skin recommended by WHO (1984, cited in Hemsworth, 2000). This involves stretching the skin flat between the finger and thumb. It is a good technique for obese patients/clients. 3. Z-track technique. The Z track technique is recommended for all intramuscular injections (Beyea & Nicoll, The Z track technique involves pulling the underlying skin to one side of the injection site (which moves the cutaneous and subcutaneous tissues by approximately 1 2 cm (Workman, 1999)), inserting the needle at a right angle to the skin, drawing back, giving the injection, removing the needle and then releasing the skin (Mallett & Dougherty, 2000; Workman, 1999). The Z track technique acts as a shutter, sealing the point of entry of the needle into the muscle so that medication is prevented from backtracking, oozing and irritating subcutaneous tissue. However, this technique may be difficult with a child who is not cooperating. The Z track may be recommended by the manufacturer for drugs that potentially damage or stain the skin, e.g. depot injections and iron injections. 156

159 When identifying the site for injection, it is important to remember that moving the skin may distract you from the intended destination ALWAYS DOUBLE CHECK. Once the technique has been decided Inject the fluid steadily and slowly; about 1ml per 10 seconds to allow the muscle to accommodate the fluid (Farley et al, 1986; Keen, 1990; Workman, 1999). Withdraw the needle at the same angle as it entered. Do not massage the site afterwards, but be prepared to apply gentle pressure with a gauze swab (Beyea & Nicoll, 1996; Bolander, 1994 cited in Rodger & King, 2000; Hemsworth, 2000; McConnell, 1993). The choice of site for an intramuscular injection depends upon a number of factors: the volume of fluid to be administered and whether or not there is sufficient muscle mass to accommodate this: does the site have a good blood supply? is there any skin damage? is there any evidence of fibrosis or infection? is the drug recommended in a particular site by the manufacturer? Deltoid muscle only used for injections of 1 ml or less in volume, of clear non-irritating fluid (Hogston & Simpson, 20002; Mallett & Dougherty, 2000). This site is often used for vaccines such as hepatitis B or tetanus. This site is useful for small volumes in children and adults as it has a good blood supply allowing fast absorption (Hemsworth, 2000). The muscle is located in the lateral aspect of the upper arm; the elbow should be flexed and supported so that the muscle can relax. Locate the lower edge of the acromion process with one hand and then identify the area on the lateral aspect of the upper arm that is in line with the axilla (Swearingen, 1991) Rectus femoris muscle This site can be located midway between the patella and superior iliac crest on the mid-anterior aspect of the thigh (Bolander, 1994 cited in Rodger & King, 2000). The uptake of drugs from this site is slower than from the arm but faster than from the buttock (Newton et al, 1992). Injections into this site may cause significant discomfort and so should only be used when other sites are contra-indicated or for patients/clients who administer their own medication (Kozier et al, 1993). Vastus lateralis muscle (outer aspect of the middle third of the thigh) Can be used for both adults and children having easy access and no major blood vessels or significant nerve structures assocated with this site. However, there is a risk of damage to the femoral nerve and quadriceps contracture when repeated injections are given in children (Bergeson, 1982; Losek & Gyuro, 1992 both cited in Hemsworth, 2000). Can accommodate volumes up to 5ml although in infants and small children 1 ml is the maximum volume that should be administered in a single site (Wong et al, 1999). Ask the patient to point their toes inwards as this helps to relax the muscle and exposes the muscle group (Hogston & Simpson, 2002). Divide the lateral aspect (side) of the thigh between the greater trochanter of the femur and the knee, into thirds with the middle third being used as the injection site. Gluteus maximus muscle - dorsogluteal (upper outer quadrant of the buttock) Not recommended in infants who have not been walking for at least one year, as the muscle is not developed enough (Wong et al, 1999). Can accommodate volumes up to 5ml and is the preferred site for larger volumes (Hogston & Simpson, 2002) although in infants and small children 1 ml is the maximum volume that should be administered in a single site (Wong et al, 1999). Ask the patient to lie on their side with their legs slightly bent as this will help to relax the muscle. 157

160 Carry out the division of the buttock so that the correct site can be identified to avoid the sciatic nerve and major blood vessels that run through the buttock, if the sciatic nerve is hit this can cause long-term problems for the patient/client. Divide the buttock into half vertically and half again horizontally, at the height of the top of the cleft between the buttocks. Administer the injection into the upper outer quadrant (Baillie, 2001; Hogston & Simpson, 2002) Injections administered at this site have the slowest absorption rate. Ventro-gluteal muscle this has now been recommended as a safer option to access the gluteus medius muscle in both adults and children. This site is recommended as the primary location for IM injections as it avoids all major nerves and blood vessels and there have been no reported complications (Beyea and Nicholl, 1995; Workman, 1999) although this may be due to the fact that the technique is not yet widely practiced in this country. The ventro-gluteal site has a relatively consistent thickness of adipose tissue over it (3.75cm as compared to 11 to 9cm in the gluteus maximus site), which should help to ensure that the drug is given intra-muscularly rather than subcutaneously. However, this technique is not widely used in this country and so your assessor may not be competent to assess you giving an injection to this site, if this is the case you cannot give an injection by this route. The patient/client can lie in a number of positions; whichever is most comfortable, prone, supine, sitting, standing, lying on the side (Hogston & Simpson, 2002). It is the preferred site for infants and children who have not been walking for at least a year (Beecroft, 1990; Wong et al, 1999) and for the elderly, non-ambulant and emaciated patient/client whose muscle mass is likely to have atrophied and so the dorso-gluteal site would be unsuitable (Mallett & Dougherty, 2000). Can accommodate volumes up to 4ml (Mallett & Dougherty, 2000) although in infants and small children 1 ml is the maximum volume that should be administered in a single site (Wong et al, 1999).. To locate the correct site on the right hip, palpate the greater trochanter, the iliac crest and the anterior superior iliac spine. Place the palm of the left hand on the greater trochanter and point the left index finger towards the anterior superior iliac spine. Move the middle finger away from the index finger to form a V between the fingers. The thumb should be pointing towards the groin. The injection is given into the centre of the V (Kozier et al, 1993; Swearingen, 1991) Drawing up procedure Collect the equipment required. Gloves may be indicated if the drug being drawn up is likely to cause skin sensitisation with frequent use. For example, some drugs such as penicillin or chlorpromazine can result in dermatitis following frequent contact (Hogston & Simpson, 2002). Wash hands to prevent cross infection. Check that the equipment is sterile by observing for any damage to the packaging; check the expiry date of the equipment. Choose the appropriate size syringe, which should be the smallest possible to accommodate the given volume (Zenk, 1993). Volumes of less than 0.5ml should be given with low dose syringes to ensure accuracy (Zenk, 1993). Some drugs require a special syringe, e.g. insulin, as insulin is measured in units, which is how the syringe is marked. Choose a blue needle (23 gauge) for drawing up the medicine as this reduces the risk of drawing up any foreign bodies (such as glass) into the syringe (Rodger & King, 2000). Open the outer packaging of the needle and syringe but avoid touching the areas of the needle and syringe that join together. This is known as a no-touch technique. Connect the needle to the syringe and loosen the cap on the needle. Check the medication chart for the drug name, dose, route, time and date of administration. Check that the doctor s signature is present. Compare the name of the drug and dose to the ampoule containing the medication, calculate the appropriate 158

161 amount of fluid to draw up where necessary. Check the expiry date on the ampoule. During this practical session you will be using Water for Injection, which does not have a dose. Check the ampoule for cracks and the fluid for cloudiness or precipitation, if any of these are present discard and select a new ampoule as the drug may be contaminated. If glass, tap the top of the ampoule to release any of the drug into the bottom of the ampoule, snap open using a twisting technique for plastic ampoules, or an ampoule breaker for glass to protect yourself from injury. If an ampoule breaker is not available some tissue or gauze can be used. To draw up the fluid insert the tip of the needle and pull back the plunger on the syringe. If you insert the needle too far the eye of the needle will go above the level of fluid and only air will be drawn into the syringe. It may be necessary to tip the ampoule upside down to reach the fluid. If you are drawing up from a multidose vial, a newly opened vial does not require cleaning but one previously used should be cleaned with an alcohol swab for 10 seconds and allowed to dry (Baillie, 2001; Hogston & Simpson, 2002) Replace the sheath onto the clean needle. Do not confuse this with resheathing needles after the injection has been given (Mallett & Dougherty, 2000). Never resheath a used needle due to the risk of cross infection if a needlestick injury accidentally occurs. After drawing the appropriate amount of fluid into the syringe remove any small air bubbles from the fluid, avoid spraying the fluid into the air. Air bubbles will not cause the patient/client any harm during the injection but may result in the wrong dose of medication being administered. Check that you still have the correct amount of fluid required to administer the correct dose. Change the needle for a new needle of the appropriate size depending upon the injection to be given. For information relating to the disposal of sharps and the procedure to follow in the event of a sharps injury (this relates to used sharps, not accidental inoculation with a clean needle) see relevant section in your infection control workbook. References Baillie L (2005) Developing Practical Nursing Skills, Arnold Publishers, London Barnhill B J, Holbert M D, Jackson N J & Erickson R S (1996) Using pressure to decrease the pain of intramuscular injections. Journal of Pain & Symptom Management 12, Beecroft P C (1990) Intramuscular injection practices of paediatric nurses: site selection. Nurse Educator 5 (4) 23-8 Beyea S C & Nicholl L H (1995) Administration of Medication via the Intramuscular route: an integrative review of the literature and research based protocol for the procedure. Applied Nursing Research, 5 (1), (not available in UCE library but can be requested if required) Beyea S C & Nicholl L H (1996) Back to Basics: Administering IM injections the right way. American Journal of Nursing 96 (1) Chung J W Y, Ng W M Y, Wong T K S (2002) An experimental study on the use of manual pressure to reduce pain in intramuscular injections. Journal of Clinical Nursing 11, Farley H F (1986) Will that IM needle reach the muscle? American Journal of Nursing 12, Hemsworth B (2000) Intramuscular injection technique. Paediatric Nursing 12 (9), Nov Hogston R & Simpson P M (ed) (1999) Foundations for Nursing Practice, MacMillan Press, London Jamieson E M, McCall J M, Blythe R & Whyte L A (1997) Clinical Nursing Practices, 3 rd Edition. Churchill Livingstone, Edinburgh 159

162 Keen M F (1990) Get on the right tracking with Z track injections Nursing (8) 59 Kozier B, Erb G, Blais K, Johnson J & Temple J (1993) Techniques in clinical nursing (4 th Ed). Addison- Wesley, Wokingham Mallett J & Dougherty C (eds) (2000) Manual of Clinical Nursing Procedures Blackwell Science McConnell E A (1993) Clinical do s and don ts: how to administer a Z track injection. Nursing 23, 18 Newton M, Newton D & Fudin J (1992) Reviewing the three big injection routes. Nursing 2 (9) Rodger M A & King L (2000) Drawing up and administering intramuscular injections: a review of the literature. Journal of Advanced Nursing 31 (3) Simmonds B P (1983) CDC Guidelines for the Prevention of Intramuscular Infections American Journal of Infection Control, 11(5), (not available in UCE library but can be requested if required) SwearingenP L (1991) Photo atlas of nursing procedures. Addison-Wesley, Californai NMC (2002) Guidelines for the Administration of medicine. NMC, London Wong D L, Hockenberry-Eaton M, Winkelstein M L, Wilson D, Ahmann E & DiVito-Thomas P A (1999) Whaley & Wong s Nursing Care of Infants and Children 6 th Edition. Mosby, London Workman B (1999) Safe Injection Techniques Nursing Standard 13 (39) Zenk K (1993) Drug hot line: air bubble, beware of overdose. Nursing 93, 23 (3)

163 APPENDIX THREE Oral Care Evidence suggests that oral hygiene is often neglected or carried out inappropriately (Bowsher et al, 1999). Adams (1996) showed that qualified nurses lacked knowledge of mouth care. Oral hygiene is described as scientific care of teeth and mouth (Thomas 1997). Oral hygiene should be part of an assessment of the mouth on admission and should be reviewed at regular intervals. Assessing a patient s mouth and delivering appropriate oral care can prevent potential infections, distress and discomfort to a patient, as well as reducing the risk of both dental and systemic disease (Xavier 2000). 1. What are you assessing? Mucous membrane Lips Tongue Gums Teeth (Beck & Yasko 1993, Dudjak 1987, cited in Nursing Standard Volume 14, 18, 2000) Implementation Always gain the consent of the individual before carrying out oral hygiene. Maintain privacy and dignity whilst carrying out oral hygiene, consider how you would feel having your teeth brushed by someone else in full view of other people. 2. What is the procedure for carrying out oral hygiene? According to Howarth (1997) cited by Xavier (2000) it is not nil-by-mouth patients who are at greatest risk but those who are reluctant to eat or drink. 3. Why is this? 161

164 4.What problems may arise if oral hygiene is poor? Homes & Mountain (1993) found that qualified nurses often lacked the knowledge to assess the need for oral hygiene. A number of assessment tools have been developed but work is still required to develop a tool that is entirely satisfactory for use in clinical practice (Mallet & Bailey, 2000). 5. List some of the risk factors which might predispose a patient having problems with his or her oral care 6.What is the first choice of tools for maintaining oral hygiene? 7. What action should the nurse take when caring for an individual s dentures? 8.The following items are frequently used to maintain oral hygiene, why are they unsuitable? Foam sticks -. Gloved finger and gauze Lemon and glycerine swabs 8. What safety measures should be taken when cleaning the teeth of an unconscious patient? Notes from the practical session: 162

165 References for Hygiene and Oral Hygiene Adams R (1996) Qualified nurses lack of adequate knowledge related to oral health, resulting in inadequate oral care of patients on medical wards. Journal of Advanced Nursing, 24 (3) American Dental Organisation (2003) Cleaning your teeth and gums Baillie L (2001) (ed) Developing Practical Nursing Skills, Arnold, London Beck, S, L & Yasko, J, M (1993) Guidelines for Oral care in Xavier, G (2000) The importance of mouth care in preventing infection Nursing Standard 14,18, Bill, K (2000) The importance of Mouth Care Nursing Standard 14, 31, 55 Bowsher J, Boyle S & Griffiths J (1999) Oral Care. Nursing Standard 13 (37) 31 British Dental Association (1997) Toothbrushes and toothbrushing Corbett C O (1997) Mouth care and chemotherapy. Paediatric Nursing 9 (3) Coyne I T (1995a) Parental participation in care: a critical review of the literature. Journal of Advanced Nursing 21, Coyne I T (1995b) Partnership in care: parents views of participation in their hospitalised child s care. Journal of Clinical Nursing, 4, 71-9 Dudjak, L (1987) Mouth Care for mucositis due to radiation therapy in Xavier, G (2000) The importance of mouth care in preventing infection Nursing Standard 14,18, Gould D (1994) Helping the patient with personal hygiene. Nursing Standard 8 (34) 30-2 Holmes S & Mountain E (1993) Assessment of oral status: evaluation of three oral assessment guides. Journal of Clinical Nursing 2, Jones C V (1998) The importance of oral hygiene in nutritional support. British Journal of Nursing, 74, 76-8, 80-3 Kawik L (1996) Nurses and parents perception of participation and partnership in caring for a hospitalised child. British Journal of Nursing 5 (7) Kite K & Pearson L (1995) A rationale for mouth care: the integration of theory with practice. Intensive Critical Care Nursing, 11 (2) Longhurst R (2000) Bad taste of poor oral care. Nursing Times 96(46) 21. Mallet J & Dougherty L (2000) (Ed) Manual of Clinical Nursing Procedures, fifth edition. Blackwell Science, Oxon Pearson L S (2002) A Controlled Trial to Compare the ability of foam swabs and toothbrushes to remove dental plaque Journal of Advanced Nursing, 39(5) Pearson L S (1996) A comparison of the ability of foam swabs and toothbrushes to remove plaque: implications for nursing practice. Journal of Advanced Nursing, 23 (1)

166 Peate I (1993) Nurse-administered oral hygiene in the hospitalized patient. British Journal of Nursing, 2, Porter H J (1994) Mouth care in cancer. Nursing Times 90 (14) Rader J (1994) To bathe or not to bathe: that is the question. Journal of Gerontological Nursing 20 (9) Skewes S M (1997) Bathing: it s a tough job! Journal of Gerontological Nursing 230 (5) 53-9 Sloane P, Rader J, Barrick A et al (1995) Bathing persons with dementia. The Gerontologist 35 (5) (not available in UCE library but can be requested if required) Somerville R (1999) Oral care in the intensive care setting: a case study. Nursing in Critical Care 4 (1) 7-13(not available in UCE library but can be requested if required) Thaipisuttikul Y (1998) Pruritic skin diseases in the elderly. The Journal of Dermatology 25, (not available in UCE library but can be requested if required) Thomas, C, L (1997) Tabers Cyclopedic Medical Dictionary Torrance C (1990) Oral hygiene. Surgical Nurse, Trenter P & Creason N S (1986) Nurse administered oral hygiene: is there a scientific basis? Journal of Advanced Nursing 11, Xavier, G (2000) The importance of mouth care in preventing infection Nursing Standard 14,18,

167 APPENDIX FOUR Fluid Balance Chart University Hospital Someplace NHS Trust 165

168 APPENDIX FIVE Observation Chart 166

169 APPENDIX SIX Blood Pressure Measurement Technique Blood pressure is the force exerted by blood against the walls of the vessels in which it is contained. Pressure is highest during systole when the ventricles are contracting (systolic pressure) and lowest during diastole when the ventricles are relaxing and refilling (diastolic pressure) Blood pressure is adjusted to its normal level by the sympathetic nervous system and hormonal controls; systolic pressure is normally at its lowest during sleep and can be raised by exertion, fear, stress and excitement. Blood pressure can vary between individuals and depends on age, fitness and general physical and emotional health. Blood pressure is measured in millimeters of mercury (mmhg) Measuring blood pressure gives important clues about an individual s health and well being. It may be used as a baseline against which subsequent readings can be compared and allows monitoring of the effects of drugs, disease and surgery on the circulatory system (Marieb, 1998, Hinchcliffe, Montague & Watson 1988) The skills session is concerned with the measurement of blood pressure using the non invasive, manual method with a mercury syphgmanometer. There is environmental pressure to reduce the use of mercury as it is considered a hazardous substance and the introduction of the Control of Substances Hazardous to Health (COSHH) Regulations by the Health and Safety Executive, which includes Mercury, has lead to many Trusts removing glass thermometers and to replace mercury syphgmanometers with automated devices when the opportunity arises. There is no UK wide ban on the use of medical devices containing mercury at present, although the European Commission is investigating whether further regulatory action is required to restrict the use of Mercury, this report due for completion in July 2002 has not been published yet. (See advice on dealing with mercury spillage) Many health care settings use automated devices such as the DINAMAP and as there is a wide range of automated devices available, it is beyond the scope of this chapter to discuss them all. You would need to be trained in their use by an appropriate staff member. Despite these issues it is important that you are able to use a mercury syphgmanometer as automated devices sometimes fail or throw up erroneous readings (O Brien et al 2001 a ) and the mercury syphgmanometer is still considered the gold standard for blood pressure measurement (British Hypertensive Society 2000). It should also be noted here that aneroid syphgmanometers (those with a dial face) are considered unreliable and need regular calibration every six months (Burke et al 1982, O Brien et al, 2001 b, Feather, 2001, Murray & Ireland 2001) The British Hypertensive Society, European Society of Hypertension and the US Association for the Advancement of Medical Instrumentation (AAMI) are the only agencies that independently evaluate measurement devices for accuracy and a full list of recommended measurement devices, both manual and automated, can be found on the British Hypertensive Society website. Procedure: 1: Wash your hands with soap and water to remove any transient organisms (ICNA, 1999) 2: Check that your equipment is clean, in good working order and that the syphgmanometer has been calibrated. The glass tube may become dirty due to oxidization of the mercury, giving poor legibility of the gauge and causing mercury to stick to the tube when the pressure is released which results in overestimation of blood pressure. Blocked air vents make inflation more difficult and the mercury is slow to respond to an increase or decrease in pressure, which can also lead to overestimation. The control valve must tighten and loosen easily and not leak, which would cause an underestimation of systolic pressure and 167

170 overestimation of diastolic pressure. The tubing should be checked for signs of leakage caused by perished or punctured rubber. Similarly the bladder must also be in good condition, intact and not leaking air (Burke et al, 1982, Beevers, Lip, O Brien, 2001) 3: Give a full explanation of the procedure to the patient, ensure that they give their consent and are as relaxed as possible. Anxiety can raise the blood pressure by as much as 30mmHg, this is a normal physiological reaction often referred to as the flight or fight phenomenon (Beevers, G, Lip, G, O Brien, E, 2001, Marieb, 1998, Hinchliff, Montague & Watson 1988) 4: The blood pressure must always be recorded under the same circumstances each time it is taken i.e. with the patient always sitting, standing or lying Posture affects blood pressure, with a general tendency for it to increase from the lying to the sitting or standing position (Beevers, G, Lip, G, O Brien, E, 2001) Whilst these changes are not likely to introduce major error, it is advised by Beevers, Lip and O Brien (2001) that posture is standardized for individual patients. Whichever position is chosen the patient must be comfortable with their arm supported at heart level. If the arm is unsupported, isometric exercise is performed raising the blood pressure and heart rate. Diastolic blood pressure may be raised by as much as 10% by having the arm extended and unsupported during blood pressure measurement (Beevers, G, Lip, G, O Brien, E, 2001) 5: It has been suggested that the blood pressure should always be measured in the same arm as inter-arm differences have been reported (Gosse 2002, Lane et al 2002) It is for this reason that it is recommended that the blood pressure is recorded in both arms on a first consultation (World Health Organisation, International Society of Hypertension 1999) If there is a difference the arm with the higher pressure should be used for future measurements. Should the inter arm difference be greater than 20mmHg for the systolic or 10mmHg for the diastolic on three consecutive readings the patient should be referred on to a cardiovascular center for further evaluation (Beevers, G, Lip, G, O Brien, E, 2001) 6: The patient should sit or lie quietly for three minutes with their legs uncrossed and their arm supported at the level of the heart. Ensure that there is no tight clothing on the arm and remove if necessary (Beevers, G, Lip, G, O Brien, E, 2001, McAlister, F & Straus, S 2001, British Hypertension Society 1999) 7: The syphgmanometer must be positioned on a flat, level surface. Its height compared to the patient does not affect the accuracy of the measurement, but it should be at eye level and within 1m of the observer (O Brien et al 2002, Beevers, G, Lip, G, O Brien, E, 2001) 8: The cuff is a fabric band that contains an inflatable rubber bladder; it encircles the arm and is secured either by Velcro or by tucking the tapering end of the fabric in on itself. The midline of the bladder needs to be over the arterial pulse and the lower edge of the cuff should be 2-3 cms above the point of the palpated arterial pulse. It is recommended that the rubber tubing from the bladder are placed so that they arise from the top of the cuff and therefore do not get in the way when palpating the pulse and later placing the stethoscope. It is essential that the correct cuff size is selected, too small (undercuffing) and the blood pressure will be overestimated, too large (overcuffing) and the blood pressure will be underestimated (O Brien et al 2002, Beevers, G, Lip, G, O Brien, E, 2001, McAlister & Straus 2001, Burke et al 1982, Drevenhorn et al 2001) To choose the correct size cuff, estimate the circumference of the bare arm at the midpoint between the shoulder and the elbow by inspection or tape measure and select an appropriate cuff. The bladder inside the cuff should encircle 80% of the arm (Perloff et al, 1993, Bailey & Bauer 1993). The width of the cuff should be equal to 40% of the circumference of the arm, (Dobbin, 2002, Bailey & Bauer 1993) 168

171 To give guidance most Authors recommend a cuff size ranging between: Child: Small adult / medium child Adult Large Adult: Very Large Adult: 4 x 13cms 10 x 18cms x cms 12.5 x 35 cms x cms (O Brien et al 2002 c, Thulin et al 1982) 9: The operator s position is also important, it is advised that you are relaxed and comfortable with the eyes level with the top of the mercury column. Errors will occur if the eye is not kept level with the meniscus. Other sources of observer error can include, lack of concentration, poor hearing and terminal digit preference; this refers to the observer rounding off the reading to a digit of their choosing, commonly zero or five (Beevers et al 2001) 10: Check the pulse rate & rhythm at the radial artery in the wrist and note any arrhythmias. An arrhythmia is when the cardiac rhythm is irregular and there can be large differences in blood pressure from beat to beat. In bradyarrythmias, when the cardiac rhythm is slow and irregular it is important that the deflation of the cuff is slower than normally employed as too rapid deflation of the cuff leads to underestimation of the systolic pressure and over estimation of diastolic pressure. (Beevers et al 2001) 11: Estimate the systolic pressure by feeling for the brachial artery, then inflate the cuff rapidly until the pulse disappears, inflate a further 20-30mmHg beyond this. Then as you slowly let down the cuff feel for the return of the brachial pulse and note at what level it was first felt. This gives you the estimated systolic pressure. Estimating systolic pressure ensures that none of the sounds are missed on auscultation, as occasionally phase I sounds disappear as the cuff is released and reappear at a lower level, a phenomenon known as the auscultatory gap. Some authors recommend that the estimated systolic pressure is done using the radial pulse whilst others recommend the brachial, however by using the brachial artery the observer has established its location prior to auscultation. Either way the principle remains the same and it is an essential part of the blood pressure measurement technique (British Hypertensive Society 1999, Beevers et al 200) 12: Check that your stethoscope is switched to the diaphragm rather than the bell by twisting the end of the stethoscope to ensure that it is activated; this can be checked by tapping the diaphragm gently Diaphragm use is recommended as it covers a wider area and is easier to secure with the fingers of one hand (British Hypertension Society, 1999, Beevers et al 2001) Ensure that the ear pieces are angled forward into the external auditory canal to optimize hearing. If the earpiece is angled against the pinna it may prevent accurate auscultation. 13: The cuff is inflated to 30mmHg higher than the estimated systolic pressure (Beevers et al 2001, Jevon et al 2001, Drevenhorn et al 2001) to ensure that any auscultory gap is accounted for and none of the Korotkoff sounds missed. 14: Place the diaphragm of the stethoscope over the brachial artery and secure using the fingers of one hand (British Hypertension Society, 1999, Beevers et al 2001) 15: Deflate the cuff slowly, approximately 2-3mmHg per second (Feather, 2001, Beevers et al 2001, Jevon 2001) whilst listening carefully for the first Korotkoff sound and observing the slow fall of mercury within the glass tube of the syphgmanometer (British Hypertension Society 1999, Hinchliff et al 1999) The level of the mercury when you hear the first sound gives the systolic blood pressure. and the last Korotkoff sound when they finally disappear, 169

172 is the diastolic blood pressure. After the last Korotkoff sound is heard the cuff should be deflated slowly for a further 10mmHg to ensure no further sounds are heard, then rapidly deflate the remainder of the cuff (Perloff et al 1993) If the sounds continue to zero then record the sound as it becomes muffled and document this fact. Record to the nearest 2mmHg (British Hypertension Society, 1999) 16: The number of times the reading is repeated is dependant on the clinical condition of the patient, however if there is uncertainty over the reading there may be a need for several measurements. Reliability of measurements is improved by repeated measurements (Beevers at al 2001) The British Hypertension Society (1999) recommend that at least two readings are taken and that if there is a discrepancy of 5mmHg or more a third reading is required. 17: On a first consultation with a patient it is recommended that the blood pressure be taken in both arms and any discrepancies noted (British Hypertension Society 1999, Gosse, P.2002, Lane et al 2002) Should the inter arm difference be greater than 20mmHg for the systolic or 10mmHg for the diastolic on three consecutive readings the patient should be referred on to a cardiovascular center for further evaluation (Beevers, G, Lip, G, O Brien, E, 2001, Lane et al 2002) 18: It is recommended that there is a 30 second 3 minute gaps between repeated inflation of the cuff (British Hypertension Society 1999, Perloff et al, 1993) to avoid venous congestion. 19: Record the reading accurately on the patient s observation chart according to local policy and report any deviations from their normal range or baseline reading (Jevon et al 2001). Normal Ranges: Adult: Systolic Diastolic <150 <90 (Audit Standard) however the British Hypertension Society (1999) recommend; <140 <85 <140 <90 (in adults with Diabetes) (British Hypertension Society 1999, James et al 2002, Hinchliff et al 1999) Child: Systolic Diastolic <1 year years years years (Mackway-Jones et al, 2001, MacGregor, J.2000, Wong, D. 2000) Special Groups: Children: there are several difficulties with measuring blood pressure in children, there is greater variability in their blood pressure than in adults and so any one reading is less likely to be an accurate representation of the true blood pressure. In addition Korotkoff sounds are not reliably heard in all children under one year and in many under fives, therefore more sensitive means of measurement may be required such as Doppler or oscillometry (Mackway-Jones et al, 2001, MacGregor, J.2000, Wong, D. 2000, Beevers et al 1999) 170

173 Older Adults: again are subject to considerable blood pressure variability, which can lead to circadian blood pressure patterns that will only be picked up by using ambulatory blood pressure measurement. The clinical consequence of these varying readings dependant on the time of day and level of activity is that one off blood pressure readings can be inaccurate and misleading Beevers et al (1999) Being Overweight: The link between obesity and hypertension has been well established. Beevers et al (1999) comment that there are at least two components, firstly there is a pathophysilogical connection and there is the possibility that in some cases the two conditions are causally linked. Secondly if this is not accounted for it may result in inaccurate blood pressure readings. Extra care needs to be taken in ensuring that the cuff and bladder size are appropriate for the arm circumference. Obesity may affect the accuracy of blood pressure measurement in children, young people, the elderly and pregnant women Beevers et al (1999) Pregnancy: Accurate measurement of blood pressure is essential as 10% of pregnant women will be clinically hypertensive and in a substantial number of these, medical decisions about the pregnancy will be made. High blood pressure in pregnancy has important implications for patient management if maternal and fetal health is to be maintained. Obstetricians agree that the disappearance of sounds is the most accurate measurement of diastolic blood pressure. However in the rare instances when the sounds continue to zero the fourth phase, when sound muffle, should be recorded. (Beevers et al 1999, Brown et al, 1998) Dealing with a mercury spillage safely When dealing with a mercury spillage, Beevers et al (1999) recommend wearing latex gloves and avoiding prolonged inhalation of mercury vapour. Collect all the small beads of mercury into one large globule and then transfer this to a container that must be sealed. After removal of the mercury, treat the contaminated surface with equal parts calcium hydroxide and powdered sulphur mixed with water to form a thin paste. Apply this paste to all the contaminated surfaces and allow to dry. After 24 hours remove the paste and wash the surfaces with clean water. Allow to dry and ventilate the area. Most Trusts have a mercury spillage kit and an incident form will have to be completed. Blood Pressure Measurement: References Marieb, E.N. (1998) Human Anatomy & Physiology. Benjamin/Cummings Hinchliff, S.M, Montague, S.E & Watson, R. (1999) Physiology for Nursing Practice. 2 nd Edition. Bailliere Tindall. London. British Hypertension Society 2000 ICNA collaboration 1999 Guidelines for Hand Hygiene. Infection Control Nurses Association in with Deb Hygiene. Burke et al 1982 Syphgmanometers in hospital and family practice: problems and recommendations. British Medical Journal. August 14. Vol 285. p Feather, C Blood pressure measurement. Nursing Times. January 25, Vol 97, No 4, p

174 O Brien, E. Beevers, G. Lip,YH a ABC of Hypertension: Blood pressure measurement, Part IV Automated syphgmomanometry; self blood pressure measurement. British Medical Journal. May 12. Vol 322. p O Brien at al 2001 b Blood pressure measuring devices: recommendations of the European Society of Hypertension. British Medical Journal. March 3. Vol 322. p Murray, A. Ireland, J. (2001) In praise of mercury syphgmomanometers. (Letter to the Editor) British Medical Journal. May 19, v322, i7296, p1248. Beevers, G, Lip, G, O Brien, E (2001) ABC of Hypertension. 4 th Edition. BMJ Books, London. P McAlister, F & Straus, S (2001) Measurement of blood pressure: an evidence based review. British Medical Journal. April 14, Vol 322, p O Brien et al. (2002) Working Group on Blood Pressure Monitoring of the European Society of Hypertension International Protocol for validation of blood pressure measuring devices in Adults. Blood Pressure Monitoring. Vol 7, N o / 1, p Gosse, P Journal of (2002) Blood pressure should be measured in both arms on the first consultation. Hypertension, 20 p Lane, D et al (2002) Inter-arm differences in blood pressure: when are they clinically significant? Journal of Hypertension, Vol 20, N o /6, p WHO (1999) Guidelines subcommittee World Health Organization International Society of Hypertension, guidelines for the management of hypertension. Journal of Hypertension 17: Drevenhorn, E. et al (2001) Blood pressure measurement an observational study of 21 public health nurses. Journal of Clinical Nursing, 10: Perloff et al (1993) cited in McAlister, F & Straus, S (2001) Measurement of blood pressure: an evidence based review. British Medical Journal. April 14, Vol 322, p Bailey, R.H., Bauer, J.H (1993) A review of common errors in the indirect measurement of blood pressure Syphgmonamometry. Archives of Internal Medicine 153 (24) p Dobbin, K.R (2002) Noninvasive blood pressure monitoring (Protocols for Practice: Applying Research at the Bedside) Critical Care Nurse, 22 (2) p.123. O Brien et al c (1997) Blood Pressure Measurement: Recommendations of the British Hypertension Society. London, BMJ Books 172

175 Thulin et al (1982) cited in Drevenhorn, E. et al (2001) Blood pressure measurement an observational study of 21 public health nurses. Journal of Clinical Nursing, 10: Feather, C. (2001) Blood pressure measurement. Nursing Times, Vol 97, N o 4, p Jevon, P, Ewens, B, Holmes J (2001) Measuring lying and standing BP 2 Nursing Times 97, (3) p Hinchliff, S, Montague, S, Watson, R. (1999) Physiology for Nursing Practice. 2 nd Edition. London, Bailliere Tindall, p Brown, M. Buddle, M. Farrell, T. Davis, G. Jones, M. (1998) The Lancet, 352 (9130) p Ramsey, L. E et al (1999) British Hypertension Society guidelines for hypertension management 1999: summary. British Medical Journal, September 1999, 319, p James, J. Baker, C. Swain, H. (2002) Principles of Science for Nurses. Oxford, Blackwell Publishing. p.143. Mackway-Jones, K. Molyneux, E. Phillips, B. Wieteska, S. Editors. (2001) Advanced Paediatric Life Support: The Practical Approach. 3 rd Edition. London, BMJ Books. P.11 MacGregor, J. (2000) Introduction to the Anatomy and Physiology of Children. London, Routledge. p.63 Wong, D. (2000) Paediatric Quick Reference. 3 rd Edition. London, Mosby. p Gosse, P. (2002) Blood pressure should be measured in both arms on the first consultation. Journal of Hypertension, 2002,20: Lane, D. Beevers, M. Barnes, N. Bourne, J. Malis, J. Beevers D. G. Inter-arm differences in blood pressure: when are they clinically significant? Journal of Hypertension, 2002;20:

176 APPENDIX SEVEN GM4078 Core Skills and their Theoretical Frameworks Revision questions 1. A curvature of the spine is called: - a. Myelitis b. Poliosis c. Myelosis d. Scoliosis 2 The following can not be used when manual handling: a Slide Sheets b Australian lift c A Hoist d Monkey Pole 3 If a patient is falling and cannot be persuaded to stand you should: a Support the patients weight b Let them collapse on the floor c Allow them to slide to the floor d Let the patient grab onto you. 4 An important principle to prevent needlestick or innoculation injury is a Use an appropriate size needle b Never resheath needles c Always wear gloves d Always wear sterile gloves MRSA stands for: - a. Multiple resistant staphylococcus aeroginosis b. Methicillin resistant streptococcus aureus c. Multiple resistant streptococcus aureus d. Methicillin resistant staphylococcus aureus The release of the stress hormone cortisol has the following effect: - a. Suppresses immunity b. Stimulates immunity c. Boosts wound healing d. Increases antibody production 7 If you felt stressed about the level of your workload, what is the best course of action you could take? a Keep quiet about it and hope it will go better soon b Make sure to discuss the situation at your next supervision session c Accuse your manager of not having your best interests at heart d Go off sick 174

177 8 According to Hall (1969), what is the optimum distance for interpersonal communication to occur a 0ins-18ins b 18ins-45ins c 45ins-120ins d 120ins-360ins 9 When actively listening which of these communication skills would you use to encourage the flow of conversation a Fold your arms b Closed questions c Breaking eye contact d Gestures 10 Gaseous exchange involves the transfer of:- a Carbon dioxide and oxygen from the alveoli into the blood. b Carbon dioxide and oxygen from the blood into the alveoli. c Carbon dioxide into the alveoli and oxygen into the blood. d Carbon dioxide into the blood and oxygen into the alveoli. 11 When assessing sputum what might lead you to suspect pulmonary oedema a It appears to be rusty / golden yellow colour b It appears to be thick yellow /green-brown colour c It appears to be watery & frothy with a pink colour d It appears to be mucoid & may be frothy with a white grey colour. 12 Orthopnoea means a Temporary absence of breaths b Fast breathing rate c Laboured or difficulty breathing d Difficulty breathing when lying down 13. Smoking cigarettes does the following to the respiratory system: - a Inhibits the action of cilia. b Causes bronchoconstriction. c Increases secretion of mucus. d All of the above. 14 The amount of air taken in during normal quiet breathing is the: - a. Vital capacity b. Total lung capacity c. Tidal volume d. Residual volume 175

178 15 Which type of sputum would you expect a patient with pulmonary oedema to have? a Green and thick b Pink and Frothy c Brown and thick d Brown and runny 16 Cigarette smoking increases lung cancer because it: - a. Damages the DNA of the lung cells b. Prevents cell division of the lung cells c. Inhibits ribosome function d. Increases mucus production 17 A sporadic cancer is most likely to: - a. A inherited genetic defect b. Occur at a younger age c. Be the same cancer suffered by several members of a family d. Largely due to environmental factors 18 Blood pressure is determined by: - a. Cardiac output x stroke volume b. Cardiac output x Heart rate c. Vascular resistance x Heart rate d. Cardiac output x Vascular resistance 19 Blood ejected by the heart travels through the following vessels in order of flow: - a. Arteries, veins, arterioles, capillaries b. Arteries, arterioles, capillaries, veins c. Arteries, capillaries, arterioles, veins d. Arteries, veins, capillaries, arterioles 20 Estimating systolic blood pressure by palpating the pulse a Ensures none of the sounds are missed on auscultation (listening) b Is unnecessary c Allows the nurse to check the equipment is working correctly d Allows the patient to get used to the tight cuff on their arm 21 Tachycardia means a Increased stroke volume b Decreased stroke volume c A slow pulse rate d A fast pulse rate 22 Proteins are made of: - a. Simple sugars b. Fatty acids c. Amino acids d. Phospholipids 23 When the action of swallowing is difficult to perform, painful or when food is delayed in its passage to the stomach it is known as a Dysplasia b Dysphonia c Dysphagia d Dysphasia 176

179 24 Which of the following would not be considered when feeding a patient a Food selection patient preferences. b Patient positioning c Choosing suitable utensils d Measuring Body Mass Index 25 Which of these conditions is associated with persistent diarrhoea and vomiting: a. Rickets b. Oedema c. Cardiac arrhythmia d. Hypertension 26 When measuring the hourly urine output there should be a minimum of a 10mls an hour b 20mls an hour c 30mls an hour d 40mls an hour 27 The insensible loss is a Fluid lost through the urine output b Fluid lost through excessive vomiting c Fluid lost through diarrhoea d Fluid lost through sweating & respiration. 28 If a patient is pyrexic do they have: - a. Normothermia b. Hyperthermia c. Hypothermia d. Polythermia 29 Which one of the following methods of heat loss is most increased, if you open a window, or use a fan: - a. Conduction b. Covection c. Radiation d. Evaporation 30 Hypothermia is a temperature below a 38 o C b 37 o C c 36 o C d 35 o C 31 Your patient s temperature is 38.5 o C, they feel unwell and shivery, you should not a Encourage oral fluid intake b Give antipyretic drugs e.g. Paracetamol. c Tepid sponge & use fan therapy d Move the patient from a hot room 177

180 To answer questions consult the following urinalysis table:- URINALYSIS A B C D E F COLOUR Dark Straw Light Dark straw Straw Straw straw hazy straw hazy Volume (ml/24hrs) Glucose Neg Trace Neg Neg +++ Neg (mmol/l) Bilirubin Neg Neg Pos Neg Neg Neg (µmol/l) 20 Ketones Moderate Neg Neg Neg Small Neg (mmol/l) Specific gravity Blood Neg ++ Neg Haemolysed ++ Neg (erythrocytes /µl) Moderate Trace Moderate ph Protein (g/l) Neg ++ + Trace ++ Neg Urobilinogen Pos Pos (EU/dl) Nitrite (µmol/l) Neg Neg Neg Neg Neg Pos Leucocytes (cells/µl) Neg Trace Neg Neg Neg ++ Moderate 32 Which urine sample is that of an alcoholic: - a. Sample B b. Sample C c. Sample E d. Sample F 33 Which urine sample is of a vegetarian with a urinary tract infection: - a. Sample B b. Sample C c. Sample E d. Sample F 34 Which urine sample is of a patient with glomerulonephritis and hypertension: - a. Sample B b. Sample C c. Sample E d. Sample F 35 Which urine sample is of a dehydrated marathon runner: - a. Sample B b. Sample C c. Sample D d. Sample E 36 Absorption of a drug involves: - a. The movement of drug around the gut b. The movement of the drug into the blood stream c. The movement of the drug into the urine d. The movement of the drug into sweat 178

181 37 For a drug to be able to affect a tissue it must be: - a. Bound to plasma proteins in the blood b. Bound to red blood cells c. Unbound drug circulating in the blood d. Unbound drug in the urine 38 If you are unsure what a prescribed drug is you should a Give it anyway as it is prescribed correctly by a doctor b Look up the drug in the British National Formulary (BNF) c Ask the patient as they have been taking it for years. d Withhold the drug and wait until the next drug round. 39 Which of the following would you consider to be a psychological sign of depression? a Poor sleep b Tearfulness c Lack of appetite d Low self esteem 40 When coming across a casualty who has collapsed, at what point should you go for help? a As soon as you discover the casualty b When you are certain that the casualty is not breathing. c If there is no pulse d It depends on the age of the casualty 179

182 Short answer questions 1. Label all regions of the spine (2): - 2. Name 2 forces acting on the spine (2). 3. Name 3 employee responsibilities in moving and handling (3). 4. Name one group of people most at risk of MRSA (1). 5. Name a bacteria commonly associated with food poisoning (1). 6. Explain how athlete s foot may be transmitted (1). 7. What conditions are ideal for the growth of the fungus causing atheletes foot (1)? 8. Name 4 factors that may increase a person s risk of poor oral health.(4) 9. Why are certain areas of the body at increased risk of pressure ulcer development?(1) 10. Name two functions of lipids (2). 11. Name 2 factors that could affect drug absorption if administered orally (2). 180

183 APPENDIX EIGHT Sample Answer sheet for Multiple Choice Questions 181

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