Study notes 004

Course Coordinator: Tracey Konig - tkonig@eit.ac.ac.nz

Lecturers: Jody Boston & Mia Fletcher

Jody Boston - jboston@eit.ac.nz

Mia Fletcher - mflether@eit.ac.nz

• Assessment Key Points

• Medication Calculation Assessments

  • 3 certificates due 5th August (4, 7, 8)

  • 3 certificates due 23rd September (9, 11, 17)

• Written Assignment based on clinical scenarios - DUE 5th September @ 2359 hrs (40%)

• Group Presentation - 23rd September

• Pre-practicum - 24th and 25th September

• Practicum - 30th September to 22nd of November 8 weeks split into 4 weeks mental health placement and 4 weeks acute care setting (264 hrs)

• Practicum Evidence portfolio

• Examination 26th November (50 %)

The Acute Presenting Patient

Objectives:

(1) Outline triage requirements, and routine investigations in assessment

(2) Briefly outline the nursing interventions for a variety of acute presentations.

(3) Discuss identification of the deteriorating patient

(4) Overview of the EWS systems

(5) Recognising the risk of violence

(1) Outline triage requirements, and routine investigations in assessment

Triage requirements in acute assessment include:

• Vital observations like;

  • temperature

  • blood pressure

  • pulse

  • respirations

  • Sp02

  • Pain score

  • last voiding

• Cognitive assessment using AVPU scale and GCS if relevant

• History of presenting complaint using OLDCARTS

• Musculoskeletal assessment for injuries

• Neurovascular assessment for limb injuries

• Medication review for allergies and applying identification bands before administration

Routine Investigations involve:

• baseline assessments to determine patient condition and aid in treatment decisions

(2) Briefly outline the nursing interventions for a variety of acute presentations.

Nursing interventions for acute presentations include:

• managing vital observations

• positioning for symptom relief

• evaluating symptoms’ causes

• providing intravenous access

• conducting blood tests

• assessing the patient’s history

For example, in respiratory distress, interventions involve ABCs, oxygen application, ECG, IV access, and blood tests

In chest pain cases, interventions include ABCs, oxygen application, ECG monitoring, IV access , and pain assessment

Orthopaedic/musculoskeletal interventions include:

• RICE method

  • stands for Rest, Ice, Compression, and Elevation. It is a common treatment approach for injuries such as sprains and strains. Rest allows the injured area to heal, Ice helps reduce swelling and pain, Compression aids in reducing swelling, and Elevation helps to decrease swelling by allowing fluids to drain away from the injured area

• vital observations

• neurovascular checks

• positioning for comfort

• analgesia

• removing jewelry

Abdopain interventions consist of ABCs, vital observations, NBM, IV access, blood tests, urine analysis, and reviewing the patient’s history

(3) Discuss identification of the deteriorating patient

The identification of the deteriorating patient involves using EWS charts to monitor vital signs and escalate care when necessary

By regularly assessing vital signs healthcare providers can identify patients who are most unwell and in need of urgent medical attention

This process includes a graded scoring system to detect early deterioration and provide increased treatment levels

Additionally, mandatory escalation of care is implemented for patients requiring immediate medical intervention

This approach helps healthcare professionals recognise clinical deterioration in patients and initiate timely interventions to prevent further decline

(4) Overview of the EWS systems

The EWS system is a method to identify deteriorating patients by using vital signs to determine the severity of illness

It includes a graded scoring system to monitor patients, escalate care when necessary, and ensure urgent medical attention for those in need

The system provides a pathway for nurses to follow as EWS increases, prompting actions like treating pain, increasing observation frequency, and involving senior medical staff for review within specific timeframes

The ultimate goal is to recognise early signs of deterioration and provide appropriation care promptly

(5) Recognising the risk of violence

Recognising the risk of violence involves identifying early signs of agitation such as:

• pacing

• gesturing

• increased voice volume

• restlessness

• irritability

It is crucial to call for help early, avoid confronting a violent person alone, prioritise personal safety, retreat to a safe location, approach calmly, avoid sudden gestures, and focus discussions on the present rather than past grievances

This proactive approach helps prevent escalation and ensures safety for all involved

Mental Health Interventions

(1) Identify and discuss brief interventions that you can use in your practice

(2) Consider how the interventions could impact patients and their families

(3) Awareness of the cycle of change in relation to addiction counselling

(4) Refresh knowledge on de-escalation skills

(1) Identify and discuss brief interventions that you can use in your practice

Brief Interventions that can be used in practice include:

• giving feedback

• building resilience

• assessing readiness to change

• relapse prevention

• short-term talking therapies

• self-care

• relaxation

• breathing strategies

These interventions aim to provide support and guidance to individuals dealing with various challenges, such as addiction or mental health issues

By implementing these strategies, practitioners can help patients make positive changes in their lives and improve their overall well-being

(2) Consider how the interventions could impact patients and their families

Brief interventions in counselling can have a positive impact on patients and their families by providing timely support, tools, and strategies to address issues such as addiction, mental health and stress

These interventions can help patients develop:

• coping skills

• improve communications

• manage emotions effectively

For families, it can lead to better understanding of the challenges faced by their loved ones, enhance communication within the family unit, and provide a supportive environment for recovery and change

Overall, these interventions aim to empower both patients and their families to navigate difficult situations and promote overall well-being

(3) Awareness of the cycle of change in relation to addiction counselling

The awareness of the cycle of change in addiction counselling involves understanding the different stages individuals go through when making behavioural changes

This includes:

• precontemplation

  • no intention to change

• contemplation

  • awareness of problem but no commitment

• preparation

  • intent on taking action

• action

  • active modification of behaviour

• maintenance

  • sustained change

• relapse

  • falling back into old patterns

By recognising these stages, counselors can tailor interventions to support individuals at each phase, such as providing feedback, assessing readiness to change, and offering relapse prevention strategies

This awareness helps counselors guide clients effectively through the process of change and address their specific needs during addiction treatment

(4) Refresh knowledge on de-escalation skills

De-escalation skills involve techniques to defuse tense situations and reduce aggression

These skills are crucial in counselling to manage challenging behaviours effectively

By using techniques like active listening, empathy, and maintaining a calm demeanor, counselors can help individuals regulate their emotions and prevent situations from escalating further.

These skills are important in addiction counselling to create a safe and supportive environment for clients to address their issues

Abdominal Assessment

(1) Review the abdominal structures & function

(2) Identify pertinent subjective data & implications

(3) Discuss process of obtaining objective data

(4) Identify common abdominal complaints, signs & symptoms

(1) Review the abdominal structures & function

The abdominal structures include the:

• inferior vena cava

• aorta

• kidneys

• duodenum

• pancreas

• small intestine

• ureters

• iliac arteries and veins

• sacral promontary

• peritoneum

• rectum

• ovaries

• uterus

• bladder

• symphysis pubis

These structures play vital roles in digestion, blood circulation, waste elimination, and reproduction

For example,

• the kidneys filter blood and produce urine

• the pancreas secretes digestive enzymes

• small intestines absorbs nutrients

• the aorta and inferior vena cava are major blood vessels supplying and draining the abdominal organs

• the peritoneum is a membrane that lines the abdominal cavity and supports the organs

Overall, these structures work together to maintain essential bodily functions in the abdominal region

(2) Identify pertinent subjective data & implications

Pertinent subjective data related to the abdomen includes:

• information about abdominal pain

  • PQRST

    • Provokes

    • Quality

    • Region

    • Severity

    • Timing

• Nutrition

  • diet recall

  • fluid intake

• medications

  • prescribed and over-the-counter

• alcohol use

• smoking hx

• recreational drug use

This data helps healthcare providers understand the patient’s abdominal health, potential causes of symptoms and overall well-being

For example,

• details about the location, severity, and timing of abdominal pain can indicate specific condition like gastritis or appendicitis

• Nutrition information can reveal dietary habits that may contribute to gastrointestinal issues

• Medication history is crucial for assessing potential side effects or drug interactions

• Details about alcohol, smoking, and drug use can provide insights into lifestyle factors that may impact abdominal health

(3) Discuss process of obtaining objective data

The process of obtaining objective data in abdominal assessment involves:

• IAPPs the abdomen in this specific order

  • Inspecting

  • Auscultating

  • Percussing

  • Palpating

• Adequate lighting, privacy, and a warm environment are essential

• It is crucial to stand on the client’s ride side, ensure relaxation, and empty bladder before the exam

• Palpate tender areas last and use distraction techniques to facilitate the assessment

This systematic approach helps gather accurate information about the abdominal structures and functions

(4) Identify common abdominal complaints, signs & symptoms

Common abdominal complaints include:

• Peritonitis

• Cholecystitis

• Gastroenteritis

• Appendicitis

• Pancreatitis

• Aortic aneurysm

• Renal issues like kidney infection or stones

• UTI

• Peptic Ulcers

• Ovarian Cyst

• Ectopic pregnancy

• Bowel obstructions

• Organ trauma

• Flatulence

• Constipation

• Irritable Bowel Syndrome (IBS)

• Crohn’s disease

• Paralytic ileus

Signs and symptoms of concern in abdominal pain assessment include:

• Fever

• Protracted vomiting

• Syncope or pre-syncope

• Evidence of gastrointestinal blood loss

The location of pain, associated signs, and symptoms are crucial in determining the cause of abdominal pain

It is important to consider special populations like women and the elderly, as they may present with atypical symptoms

Care of the Operative Patient

(1) Pre Operative Care

Focus of Pre Operative care

• Patient educaion

• Patient Safety

• Awareness helps with prevention of complications

• Baseline Assessment

• Communication & documentation

• Discharge planning

Patient Orientated Goals

• Understanding of intra-operative & post-operative events

• Maintaining a normal fluid & electrolyte balance

• Remaining free from post operative complications

• Understanding of physiological & psychological responses to surgery

• Achieving emotional & physical comfort

• A return to normal physiological function

Classifications of Surgery

• Ambulatory (aka Day surgery - DOSU)

  • Day of Surgery admission

  • Offers clients early ambulation & discharge

  • Same day discharge (maximum 23 hours stay)

  • Hospital based, satellite units, or private offices, surgical buses

• Inpatient Surgical care

  • Admitted to hospital, LOS more than 23 hours

  • Surgery classifications:

    • Elective

    • Diagnostic

    • Acute

Pre-operative Care Assessment

• Obtain history

• Physical Assessment

• Determine client’s understanding

• Identify client’s emotional state & coping skills

• Check for consent, pre-anaesthetic form complete, other pre-anaesthetic orders

Pre-operative preparation

• Documentation - complete pre-op checklist

• Check client understanding of procedure/anaesthetic

• Identification of site

• Identification of prosthesis/false teeth

• Attend to valuables/jewellery/make-up

• Hygeine needs/operative clothing

• Skin prep - tests

• Bowel prep

• Medication/pre-med orders

Pre-operative Teaching

• Improves ventilatory function

• Improves physical function activity

• Sense of well being

• Reduces LOS

• Less pain

• Better prepared family members

Delirium and Intoxication

(1) Refresh knowledge on causes and clinical manifestations of delirium

(2) Consider the acute intoxication in opioids, alcohol and methamphetamine

(3) Discuss the clinical manifestations and treatment of overdoses in opioids, alcohol, and methamphetamine

(4) Practice administration of tests, assessments and scales in different scenarios

(1) Refresh knowledge on causes and clinical manifestations of delirium

Causes of delirium include physiological changes like:

• low blood oxygen

• high carbon dioxide

• metabolic imbalances

Psychological stress from hospitalization, pain, and sleep disruption can also trigger it

Common causes are:

• infections

• trauma

• surgery

• constipation

• drug side-effects & sudden withdrawal

Clinical manifestations involve:

• acute changes in conciousness

• cognition

• inattention

• fluctuating course

• disturbances in sleep-wake cycle

• motor control

Delirium is often misdiagnosed or attributed to other conditions like dementia, emphasizing the need to differentiate between the two

(2) Consider the acute intoxication in opioids, alcohol and methamphetamine

1. Acute intoxication with opioids can lead to symptoms like:

   • respiratory depression

   • pinpoint pupils

   • altered mental status

2. Alcohol intoxication can cause:

   • euphoria

   • impaired judgement

   • even respiratory depression in severe cases

3. Methamphetamine intoxication may result in:

   • increased energy

   • paranoia

   • hallucinations

Each substance affects the body differently, but all can lead to dangerous outcomes if not managed promptly

(3) Discuss the clinical manifestations and treatment of overdoses in opioids, alcohol, and methamphetamine

1. In opioid overdose,

   • the clinical manifestations include:

     • pinpoint pupils

     • unconciousness

     • respiratory depression due to the effect on the brain regulating breathing

   • Treatment involves:

     • Naloxone administration to reverse the overdose

2. Alcohol overdose

   • can lead to symptoms like:

     • confusion

     • vomitting

     • seizures

     • slow breathing

     • hypothermia

   • treatment includes:

     • supportive care and monitoring vital signs

3. Methamphetamine overdose

   • can cause symptoms like:

     • agitation

     • rapid heart rate

     • high BP

     • confusion

     • hallucinations

   • Treatment focuses on managing symptoms like:

     • sedation for agitation

     • monitoring for potential complications like heart issues or seizures

(4) Practice administration of tests, assessments and scales in different scenarios

In the context of caring for patients with delirium, the administration of tests, assessments, and scales in different scenarios involves utilizing tools to evaluate the patient’s cognitive status, LOC, and potential causes of delirium

• These assessments may include cognitive screening tests like the:

  • Mini-Mental State Examination (MMSE) to assess cognitive impairment

  • Confusion Assessment Method (CAM) to diagnose delirium

  • Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scale to monitor alcohol withdrawal symptoms

Additionally, vital signs monitoring, electrolyte levels, and neuroimaging studies may be used to identify underlying causes such as sepsis, cerebral hypoperfusion or neuroanatomical changes

The goal is to systematically assess the patient’s condition, identify contributing factors, and tailor the treatment plan accordingly to manage delirium effectively

Maternal and Child Mental Health

(1) Review understanding of mental health

(2) Identify mental health problems during pregnancy and post natal period

(3) Discuss the effects of mental health problems on women, children, and whanau

(4) Identify risk factors, prevention and treatment

(1) Review understanding of mental health

Mental health is state of wellbeing where an individual recognizes their abilities, copes with life stresses, works effectively, and contributes to their community

It is not just the absence of disease but complete physical, mental and social wellbeing

This definition emphasizes the importance of emotional regulation, forming relationships, and learning in different contexts

(2) Identify mental health problems during pregnancy and post natal period

During pregnancy and the postnatal period, women can experience mental health problems such as:

• depression

• anxiety

• postpartum depression

These issues can be triggered by:

• hormonal changes

• physical changes

• stress

• lack of sleep

Postnatal depression for example, can manifest as mood swings, irritability, and feelings of sadness

It is important to identify these mental health problems early on to provide appropriate support and treatment for women, as they can have significant effects on both the women themselves and their families

Additionally, it’s worth noting that fathers can also experience depression during this time, highlighting the importance of mental health awareness and support for both parents

(3) Discuss the effects of mental health problems on women, children, and whanau

Mental health problems during pregnancy and postnatal periods can have significant effects on women, children and whanau (extended family).

Women may experience:

• increased stress

• difficulty bonding with their baby

• challenges in daily functioning

Children may be at risk for development delays, behavioural issues, and emotional difficulties

Whanau may face strain in providing support and care

These effects can impact the overall well-being and functioning of the family unit. It is crucial to identify risk factors, provide prevention strategies, and offer appropriate treatment to mitigate these effects and support the mental health of women children, and whanau

(4) Identify risk factors, prevention and treatment

Risk factors for mental health problems during pregnancy and postnatal period include:

• history of bipolar disorder

• previous postpartum psychosis

• family history of mood disorders

• social stressors

• substance abuse

• previous traumatic birth

Prevention involves:

• identifying these risk factors early on

• providing social support

• addressing substance abuse

• ensuring proper mental health care

Treatment may include:

• medication

• psychological interventions

• support from healthcare

• professionals

It is crucial to address these risk factors to prevent and manage mental health issues during this critical period

Eating disorders

(1) Treatment focus on individual or group counseling, with less likelihood of hospitalization.

Individual or group counselling is a key focus inn the treatment of eating disorders, aiming to provide support and therapy to individuals

This approach is beneficial as it can help address underlying issues, improve coping mechanisms, and promote recovery

By offering counselling, individuals may be able to manage their condition effectively without the need for hospitalization, unless their condition is severe and requires intensive care

Counselling can be tailored to the individual’s needs and can provide a supportive environment for healing and growth

(2) Risk factors such as low self-esteem, professional activities like dance or modeling, strict dieting history, depression, loneliness, perfectionist traits, and stressful life changes or abuse

Risk factors for eating disorders include:

• low self-esteem

• engaging in professional activities like dance or modeling

• a history of strict dieting

• experiencing depression and loneliness

• having perfectionist traits

• facing stressful life changes or abuse

These factors can contribute to the development of eating disorders due to their impact on an individual’s psychological well-being, self-image, and coping mechanisms

Additionally, societal pressures and cultural norms, such as the emphasis on thinness in Western countries, play a role in the development of eating disorders

Genetic predisposition, environmental influences, neurotransmitter dysfunction, and sociocultural factors also contribute to the pathophysiology of eating disorders

(3) Body image issues related to genetic predisposition, environmental and sociocultural factors, neurotransmitter dysfunction, and social media influence.

Body image issues can be influenced by genetic predisposition, environmental factors, and sociocultural aspects

Genetic predisposition plays a significant role, accounting for 40-60% of the causative factors

Additionally, neurotransmitter dysfunction and sociocultural influences, like societal emphasis on being thin and the impact of social media issues

These factors interact to create a complex web of influences on how individuals perceive their bodies

(4) Aetiology and risk factors predominantly seen in Western countries, with no single cause but a combination of biological, genetic, psychological, social, or cultural factors.

In Western countries, anorexia nervosa is prevalent

It is associated with being thin and is influenced by a combination of factors like biological, genetic, psychological, social, and cultural aspects

Factors such as:

• genetic predisposition

• neurotransmitter dysfunction

• sociocultural influences

• low self-esteem

• strict dieting history

• depression

• perfectionist traits

• experiences of abuse contribute to the development of Anorexia Nervosa

This complex interplay of various factors highlights the multifaceted nature of the disorder in Western societies

(5) Nursing responsibilities include monitoring physical safety, documenting vital signs, initiating refeeding processes, and documenting eating behaviors.

Nursing responsibilities include:

• monitoring physical safety to ensure the individual’s well-being

• documenting vital signs to tract heath status

• initiating refeeding processes as prescribed

• documenting eating behaviours to monitor progress and adherance to treatment plan

These tasks are crucial in providing comprehensive care and support to individuals undergoing treatment for eating disorders

(6) Specialist assessment and treatment for severe malnutrition, potential heart failure, and sudden death, involving accurate diagnosis and assessments like physical health baseline, height and weight, blood tests, ECG, bone scans, and psychiatric evaluations.

These tests include:

• establishing a physical health baseline

• measuring height and weight

• conducting health evaluations

These evaluations help in creating tailored treatment plans for individuals suffering from severe malnutrition to prevent complications like heart failure and sudden death

(7) Effects on the gastrointestinal tract due to eating disorders, including issues like pitted teeth from vomiting, inflammation, or fistulae in the throat or esophagus, and rectal bleeding from laxative overuse.

Eating disorders like bulimia nervosa can have severe effects on the GI tract

The act of frequent vomitting in bulimia can lead to pitted teeth due to exposure to stomach acid

The acid can also cause inflammation in the pharynx and esophagus, potentially leading to fistulae formation between the trachea and esophagus

Additionally, overuse of laxatives, which is common in eating disorders, can result in rectal bleeding

These issues highlight the damaging impact of eating disorders on the GI tract, offering various pars of the digestive system and potentially leading to serious complications if left untreated

Respiratory System (revision)

(1) Be able to describe the 3 processes of the respiratory system

The 3 processes of the respiratory system are:

1. Ventilation

   • is the movement of air in and out of the lungs

2. Diffusion

   • is the exchange of oxygen and carbon dioxide that occurs in the alveoli

3. Perfusion

   • in the distribution of oxygenated blood to tissues and cells in capillary beds

The processes work together to ensure that oxygen is taken in and carbon dioxide is removed from the body

(2) Know how to take a respiratory rate and oxygen saturation

To take a respiratory rate, count the number of breaths a person takes in one minute

To measure oxygen saturation, use a pulse oximeter on a person’s finger to determine the percentage of oxygen in their blood

For accuracy, ensure the person is calm and not moving during measurements

(3) Describe the signs & symptoms of respiratory distress & hypoxia

Signs and symptoms of respiratory distress includes:

• SOB

• rapid breathing

• chest pain

• wheezing

• bluish skin or lips (cyanosis)

Hypoxia symptoms include:

• confusion

• rapid breathing

• SOB

• increased heart rate

These indicate a lack of oxygen in the body, requiring prompt intervention

(4) Know when to administer oxygen & why

Oxygen should be administered when:

• prescribed

• during cardiac or pulmonary collapse/arrest

• in cases of head injury

• when oxygen saturation is less than 95%

• in the presence of heart or lung disease

Administering oxygen is crucial to treat and prevent hypoxia caused by conditions like:

• hypoxemia

• reduce respiratory effort

• lessen the workload on the heart

Hypoxia can be life-threatening, so providing supplemental oxygen is essential to prevent hypoxia, which can lead to serious consequences

(5) Identify types of devices to deliver O2 & know the correct flow rates for these devices

High flow O2 delivery devices include:

• multivent masks

  • allow manipulation of oxygen flow for precise concentration adjustment

  • Low flow devices are nasal prongs (1-4 L/min) and face masks (4-10 L/min)

  • NP can cause dry mucous membranes, while face masks may lead to claustrophobia and dryness

• non-rebreathing masks

  • delivery the highest O2 concentration with a flow rate se to >10 L/min

(6) State safety considerations with O2 administration

Safety considerations with O2 administration include avoiding flames or smoking due to oxygen’s high combustibility

High concentrations of oxygen overtime can damage the lining of the lungs

Caution is advised with known COPD or CO2 retaining patients

Oxygen should be treated as a drug, prescribed on the medicine chart, and not used as a substitute for other treatments

(7) Understand common terminology

Common terminology related to respiratory system includes:

• Tachypnoea

  • rapid breathing

• Bradypnoea

  • abnormally slow breathing

• Apnoea

  • temporary cessation of breathing

• Dyspnoea

  • difficulty breathing

• Orthopnoea

  • SOB when lying down

• Hyperventilation

  • breathing too fast

• Hypoventilation

  • breathing too shallowly

• Hypoxaemia

  • low oxygen levels in the blood

• Hypoxia

  • low oxygen levels in tissues

• Cyanosis

  • bluish discolouration of the skin due to lack of oxygen

These terms are crucial in describing respiratory conditions and symptoms

Respiratory Assessment

(1) Understand the key components and techniques of respiratory assessment

Key components of respiratory assessment include:

• Inspecting the chest for symmetry, breathing rate, and use of accessory muscles

• Palpating for tenderness or masses

• Percussing for dullness or hyperresonance

• Auscultating breath sounds for abnormalities like wheezing or crackles

Techniques involve:

• observing the patient’s breathing pattern

• feeling for any abnormalities

• tapping the chest to listen for sounds

• using a stethoscope to listen to breath sounds in different lung areas

This comprehensive assessment helps in identifying any respiratory issues or abnormalities

(2) Refresh knowledge of anatomy and function of the respiratory system

The respiratory system consists of the airways, lungs, and muscles involved in breathing

Air enter through the nose of mouth, travels down the trachea and into the bronchial tubes that lead to the lungs. In the lungs, oxygen is exchanged for carbon dioxide in tiny air sacs called alveoli

The diaphragm and intercostal muscles help with inhalation & exhalation

This system ensures oxygen is taken in and carbon dioxide is expelled, supporting cellular function and maintaining homeostasis in the body

(3) Consider and be aware of diagnostic tests

The diagnostic tests include

• Chest X-ray (CXR)

• forced expiratory time for pulmonary function assessment

• Pulse oximeter for measuring oxygen saturation

• Lung function for assessing respiratory function

• Invasive tests like bronchoscopy for direct visualisation of the airways

These tests help in evaluating the respiratory system’s structure, function, and health status

Risk Assessment Mental Health

(1) Identify components of risk assessments

(2) Identify local and nationwide initiatives for suicide prevention

(3) Discuss risk and protective factors

(4) Identify assessment tools

(5) Discuss least restrictive practice and explore tools that can be used

(1) Identify components of risk assessments

Risk assessments in mental health typically involve several key components

1. Identification of Risk Factors

   • These are characteristics or conditions that increase the likelihood of an individual engaging in self-harm or suicidal behaviour

   • Examples include:

     • history of mental illness

     • substance abuse

     • previous suicide attempts

     • significant life stressors (e.g loss of loved one, financial difficulties)

2. Identification of Protective factors

   • These are attribute or conditions that can mitigate the risk of suicide

   • Protective factors may include:

     • strong social support

     • effective coping skills

     • sense of belonging

     • access to mental health care

   • Recognizing these factors is crucial for developing a safety plan

3. Dynamic vs Static Factors

   • Dynamic factors are those that can change over time, such as mood states or current life circumstances

   • Static factors, on the other hand, are unchangeable, like a history of trauma or previous suicide attempts

   • Understanding the distinction helps in assessing the current risk level more accurately

4. Assessment tools

   • Various standardized tools can be utilized to evaluate risk, such as the Colombia-Suicide Severity Rating Scale (C-SSRS) or the Beck Scale for Suicide Ideation

   • These tools help clinicians systematically assess the severity if suicidal thoughts and behaviours

5. Least Restrictive Practice

   • This principle emphasizes providing care in the least restrictive environment possible while ensuring safety

   • It involves exploring alternatives to hospitalization and using tools like safety plans and crisis intervention strategies

6. Local and Nationwide Initiatives

   • Awareness of local and national suicide prevention programs can inform risk assessment and intervention strategies

   • These initiatives often provide resources, training, and support for individuals at risk and their families

In summary, effective risk assessments combine the identification of risk and protective factors, the use of assessment tools, and adherence to the principle of least restrictive practice, all while being informed by broader initiatives in suicide prevention

(2) Identify local and nationwide initiatives for suicide prevention

Local and Nationwide initiatives for suicide prevention in NZ include various organizations and programs aimed at addressing mental health issues and reducing suicide

1. Mental Health Foundation

   • this organization focuses on promoting mental well-being and provides resources and support for individuals struggling with mental health issues

2. Depression.org.nz

   • this is an online resource that offers information, support, and tools for individuals dealing with depression, which is a significant risk factor for suicide

3. Gumboot Friday

   • An initiative that raises funds to provide free counselling for young people, aiming to ensure that mental health support is accessible to those in need

4. Le Va - FLO

   • This program is designed to support Pacific youth and their families, focusing on culturally appropriate mental health services

5. Te Au - Waka Hourua

   • A national initiative that addresses suicide prevention specifically within Maori communities, promoting culturally relevant approaches

6. Mental Health support 1737

   • A 24/7 text and call service that provides immediate support for anyone in distress or crisis

7. Hear 4 U - Gisborne

   • a local initiative that offers mental health support and resources tailored to the Gisborne community

8. Mens Medicine - Hawke’s Bay

   • This program focuses on men’s mental health, recognizing that men often face unique challenges and barriers when seeking help

These initiatives collectively aim to address the multifaceted nature of suicide prevention by providing resources, support, and culturally relevant services to various populations, ultimately working towards reducing suicide rates in NZ

(3) Discuss risk and protective factors

Risk factors are characteristics or conditions that increase the likelihood of an individual engaging in harmful behaviours, such as suicide or self-harm

Common risk factors include:

• Mental health disorders

  • conditions like depression, anxiety, or bipolar disorder can elevate risk

• Substance Abuse

  • Alcohol or drug misuse can impair judgement and increase impulsivity

• History of Trauma or Anuse

  • Past experiences of trauma can lead to ongoing psychological distress

• Social Isolation

  • Lack of social support or feelings of loneliness can contribute to suicidal thoughts

• Chronic Illness

  • physical health problems can lead to feelings of hopelessness

Protective factors, on the other hand, are conditions or attributes that decrease the likelihood of harmful behaviours and promote resilience

Some protective factors include:

• Strong Social Support

  • close relationships with family and friends can provide emotional support

• Access to Mental Health Care

  • availability of therapy and counselling can help individuals cope with their issues

• Coping skills

  • effective problem-solving and coping strategies can mitigate risk

• Sense of purpose

  • having goals and a sense of belonging can foster hope and motivation

• Positive Life Events

  • Experiences such as employment, education, or fulfilling relationships can enhance well-being

In risk assessment, understanding the balance between these risk and protective factors is crucial for developing effective intervention strategies

This approach can help identify individuals at higher risk and implement supportive measures that leverage protective factors to enhance their resilience

(4) Identify assessment tools

Assessment tools in the context of mental health and risk assessment are structured instruments used to evaluate an individual’s mental state, risk factors for self-harm or suicide, and overall psychological well-being

Here are some commonly used assessment tools:

• Mental Status Examination (MSE)

  • this is a systematic assessment if a individual’s cognitive, emotional, and behavioural functioning

  • it includes observations of appearance, behaviour, mood, thought processes and insight

  • The MSE helps clinicians identify signs of mental health disorders and assess the severity of symptoms

• Suicide Risk Assessment Tools

  • These tools often include questionnaires or scales designed to evaluate the risk of suicide

  • examples include the Colombia-Suicide Severity Rating Scale (C-SSRS) and the Beck Scale for Suicide Ideation

  • These tools assess factors such as suicidal thoughts, plans, and previous attempts

• Beck Depression Inventory (BDI)

  • This self-report tool measures the severity of depression, which is a significant risk factor for suicide

  • It helps clinicians understand the patient’s emotional state and the potential need for intervention

• Historical Risk Factors Assessments

  • this involves exploring previous attempts of self-harm or suicide, which can be a strong indicator of future risk

  • Clinicians may use structures interviews or checklists to gather this information

• Protective Factors Assessment

  • identifying protective factors, such as social support, coping skills, and reasons for living, is crucial

  • Tools may include structured interview or scales that help assess these positive influences on an individual’s mental health

• Clinical Formulation

  • this is a comprehensive approach that synthesizes information from various assessment tools to create a holistic understanding of the individual’s mental health status and risk factors

These tools are essential for developing effective intervention strategies and ensuring the least restrictive practice, which prioritizes the individual’s rights and autonomy while providing necessary support

(5) Discuss least restrictive practice and explore tools that can be used

Least restrictive practice refers to approaches in healthcare and mental health that aim to minimize the use of coercive measures, such as seclusion and restraint, while still ensuring the safety and well-being of individuals

The goal is to provide care in a manner that respects the autonomy and dignity of patients, using the least intrusive methods possible

Tools that can be used to implement least restrictive practices include:

• Risk Assessment Tools

  • these tools help identify individuals at risk of harm and assess their needs

  • Examples include the Colombia-Suicide Severity Rating Scale (C-SSRS) and the Beck Scale for Suicide Ideation (BSSI)

  • These assessments guide clinicians in determining the appropriate level of intervention

• Crisis Intervention Strategies

  • Techniques such as de-escalation training equip staff with skills to manage crisis without resorting to restraint or seclusion

  • This includes verbal interventions and calming techniques

• Therapeutic Communication

  • Building rapport and trust with patients can reduce the likelihood of crisis situations

  • Active listening and empathetic responses are critical components

• Environmental Modifications

  • Creating a safe and supportive environment can help prevent crisis

  • This may involve adjusting the physical space to reduce triggers or providing sensory modulation tools to help individuals self-regulate

• Patient Education and Involvement

  • educating patients about their treatment options and involving them in decision-making can enhance their sense of control and reduce the need for restrictive measures

  • Techniques such as resilience training, mindfulness, and distress tolerance can empower patients to manage their emotions and reactions

Incorporating these tools into patient education can foster a collaborative approach to care, encouraging patients to engage actively in their treatment and promoting a culture of safety and respect

Research indicates that such practices not only improve patient outcomes but also enhance the overall therapeutic environment

Wound Care

(1) Competent in wound assessment, treatment, and management

(2) Acknowledges the complexity of wound management while aiming to simplify the information presented

(3) Identify resources in wound care

(4) Identify the types dressing used for the treatment of wounds

(5) Emphasize the importance of comprehensive wounds assessment, introducing tools like HEIDI (a holistic assessment tool) and TIME (an assessment of the wound bed), along with key considerations for wound evaluations

(1) Competent in wound assessment, treatment, and management

Wound assessment, treatment, and management are critical components of effective wounds care particularly in nursing practice

Wound Assessment: involves a comprehensive evaluation of the wounds and surrounding tissue

Key aspects to consider include:

• Tissue Type

  • identifying whether the tissue is necrotic, granulating, infected, epithelizing, or macerated

• Exudated

  • assessing the type (e.g purulent), volume, and odor of the wound exudate

• Peri-wound Condition

  • Evaluating the skin around the wound for integrity, inflammation, or maceration

• Pain level

  • documenting the type, history, intensity, and aggravating factors of pain, an determining if pre-medication is required

• Size

  • measuring the length, width, and depth of the wound

• Documentation

  • accurate documentation is essential, including clinical photography to track progress over time

• Treatment

  • involves selecting appropriate interventions based on the assessment findings

  • this may include cleaning the wound, applying dressings, managing infections, and addressing pain

  • Treatment plans should be tailored to the individual patient needs and the specific characteristics of the wound

• Management

  • encompasses ongoing care and monitoring of the wound

  • this includes regular reassessment to evaluate healing progress, adjusting treatment as necessary, and educating patients about wound care practices

  • effective wound management also involves collaboration with MDTs and utilizing resources from organizations such as the NZ Wound Care Society and Wound International for best practices and guidelines

Overall, a holistic approach to wound care, as highlighted by tools like HEIDI and TIME, ensures that all aspects of the patient’s condition are considered, leading to better outcomes in wound healing and patient comfort

(2) Acknowledges the complexity of wound management while aiming to simplify the information presented

Wound management is a multifaceted process that involves several critical components to ensure effective healing

Here is a simplified breakdown of its complexity:

• Assessment

  • the first step in wound management is a thorough assessment of the wound

  • this includes evaluating the type, size, depth, and condition of the wound, as well as any signs of infection

  • understanding these factors helps determine the appropriate treatment and dressing

• Dressing selection

  • choosing the right dressing is crucial

  • different goals guide this choice, such as controlling exudate, maintaining moisture, treating infection, promoting adherence of wound edges, and providing protection

  • a moist wound environment is clinically proven to enhance healing, reduce pain, and minimize scarring

• Patient Education

  • educating patients is vital for successful wound management

  • patients should be encouraged to maintain skin integrity through moisturization, especially the elderly, who are more susceptible to skin breakdown

• Nutrition

  • adequate nutrition plays a significant role in wound healing

  • A balanced intake of proteins, fats, carbohydrates, vitamins, and minerals is essential for the body’s healing processes

  • Nutritional support may be necessary for patients with deficiencies

• Medications

  • current medications can impact wound healing

  • for instance;

    • NSAIDs

    • cytotoxic drugs

    • anticoagulants

    • immunosuppressive agents can hinder the healing process

  • it’s important to review a patient’s medication history when planning wound care

• Underlying Health Conditions

  • chronic health issues such as Cardiovascular Disease (CVD), Peripheral Vascular Disease (PVD), and Rheumatoid Arthritis (RA) can significantly affect healing

  • These conditions may impair blood flow and immune response, making wound management more challenging

In summary, wound management requires a comprehensive approach that considers assessment, dressing selections patient education, nutrition, medication effects, and underlying health conditions

By simplifying these components, healthcare providers can create effective, individualized care plans that promote optimal healing outcomes

(3) Identify resources in wound care

These resources are:

• NZ Wound Care Society

  • this organization likely provides guidelines, best practices, and educational materials specific to wound care with NZ

  • it may also offer workshops, training sessions, and a community for professionals to share knowledge

• Dermnet NZ

  • this resource is a comprehensive online dermatology resource that includes information on various skin condition, including wound care

  • it likely provides evidence-base guidelines and educational materials for healthcare professionals

• Smith & Nephew

  • this is a well-known company that specialized in medical devices and wound care products

  • they provide educational resources, product information, and training for healthcare professionals on the use of their products in wound management

• Wounds International

  • this is a global organization that publishes research, guidelines, and educational materials on wound care

  • They likely offer a range of resources, including articles, webinars, and conferences focused on the last advancements in wound management

These resources are essential for healthcare professionals, especially student nurses, as they provide valuable information and support to enhance their competence in assessing treatment and managing wounds effectively

(4) Identify the types dressing used for the treatment of wounds

• Island Dressings

  • e.g Primapore, Post-op Opsite, Post-op visible (transparent), anf ASguard

  • These are primary dressings suitable for dry or low exudating wounds

  • They consist of an absorbent non-stick pad with an adhesive backing, making them ideal for post-operative wounds

  • Island dressings maintain a sterile environment, provide protection, and are available in both waterproof and non-waterproof options

  • They can typically remain in place for 3-5 days depending on the wound’s condition

• Moisture Management

  • the importance of maintaining a moist wounds environment, which is clinically proven to promote faster healing, decrease pain, and reduce scarring

  • This suggests that dressings that donate moisture or contain exudate are also crucial in wound care

• Other dressing functions

  • the various objectives that different dressings may achieve, such as:

    • treating infection

    • promoting wound edge adherence

    • debriding

    • providing extra protection

    • packing cavities

    • reducing odor

  • the choice of dressing should be dictate by a thorough assessment of the wound, considering factors like exudate levels and the need for moisture

• Considerations for Dressing selection

  • it is important to choose a dressing that is suitable for the individual patient, taking into account their comfort, cognitive function, and mobility

  • Additionally, economic implications should be considered, especially since some advanced dressing are designed to remain in place for several days and may be more costly

In summary, the main type of dressing discussed is the island dressing, but the choice of dressing should be tailored to the specific needs of the wound and the patient, considering various factors for optimal healing outcomes

(5) Emphasize the importance of comprehensive wounds assessment, introducing tools like HEIDI (a holistic assessment tool) and TIME (an assessment of the wound bed), along with key considerations for wound evaluations

Comprehensive wound assessment is crucial for effective wound management as it lays the foundation for tailored treatment plans that address the specific needs of the patient and the wound itself

Tools like HEIDI and TIME facilitate this process by providing structured approaches to evaluate various aspects of wound health

HEIDI is a holistic assessment tool that encompasses the entire individual, ensuring that all relevant factors are considered

It includes:

• History

  • Gathering medical, surgical, social, and pharmacological information to understand the patient’s background and potential influences on wound healing

• Examination

  • Conducting a thorough examination of the entire body and the specific wound to identify any underlying issues

• Investigations

  • determining necessary tests, such as blood work or swabs, to gather more information about the wound’s condition

• Diagnosis

  • Identifying the etiology and pathology of the wound to inform treatment

• Implementation

  • developing a comprehensive care plan that includes a course of treatment

• Evaluation

  • continuously monitoring and adjusting the treatment plan as needed, and referring to specialists when necessary

TIME, on the other hand, focuses specifically on the wound bed assessment

It helps identify and manage imbalances that may hinder healing:

• Tissue

  • emphasizes the need for debridement of non-viable tissue to promote healing

• Infection or Inflammation

  • addresses the management of bacterial load to prevent complications

• Moisture

  • highlights the importance of maintaining a balanced moisture level in the wound environment

• Edge

  • observes the wound edges for signs of effectiveness of the treatment

Key considerations for wound evaluations include assessing the wound’s:

• size

• depth

• exudate odor surrounding skin conditions

• as well as understanding the patient’s overall health status

By utilizing these tools and considerations, healthcare providers

Pain Assessment & Management

(1) Review the role an effects of pain

(2) Consider some of the factors that influence pain, and pain perception

(3) Review pain assessment techniques and tools

(4) Consider methods of managing pain-pharmacological an non pharmacological

(5) Introduce the concept of balanced analgesia

(6) Provide an overview of common analgesics

(1) Review the role an effects of pain

Pain serves as a crucial biological signal indicating potential or actual tissue damage, functioning as a protective mechanism for the body

It is a complex and multidimensional experience that encompasses sensory and emotional components, as defined by the International Association for the Study of Pain (IASP)

The role of pain can be understood through several key aspects:

• Protective Function

  • pain alerts individuals to harmful stimuli, prompting reactions that can prevent further injury

  • for example, the immediate withdrawal from a hot surface is a reflexive response to acute pain

• Physiological Processes

  • pain processing involves multiple interactive physiological systems, including the nervous, endocrine, and immune systems

  • This integration means that pain is not merely a physical sensation but also affects overall bodily function

• Psychological & Social Dimensions

  • pain is influenced psychological factors such as mood, anxiety, and past experiences, as well as social contexts, including support systems and cultural attitudes towards pain

  • This multidimensional nature means that pain perception can vary significantly among individuals

• Chronic Pain Consequences

  • when pain persists, it can lead to detrimental effects on physical and psychological health

  • Prolonged pain can trigger a chronic stress response

  • This can result in complications such as decreased mobility, depression, and anxiety, ultimately leading to poor treatment outcomes and higher healthcare costs

• Impact on treatment and recovery

  • The experience of pain can influence treatment efficacy

  • Patients in pain may have longer hospital stays, higher complication as it is going to be done at schools, and a greater likelihood of developing chronic pain conditions

Effective pain management is essential for improving recovery outcomes and enhancing the quality o Life

In summary, pain plays a multifaceted role in human health, serving as both a protective signal when it becomes chronic

Understanding its complex nature is crucial all around us and for effective assessment and management strategies

(2) Consider some of the factors that influence pain, and pain perception

Pain and pain perception are influenced by a multitude of factors that can be broadly categorised into biological, psychological, and social components

• Biological factors

  • Tissue damage

    • while there is a loose relationship between the degree of tissue damage and pain intensity, the actual experience of pain is not solely determined by physical injury

  • Nervous system development

    • the development of the nervous system plays a crucial role in how pain is perceived

    • for instance, individuals with altered nervous system development may experience pain differently

  • Endocrine and Immune systems

    • pain processing in integrated with these systems, meaning that hormonal changes or immune responses can influence pain perception

• Psychological Factors

  • Brain interpretation

    • pain is an output of the conscious brain, and its perception is heavily influenced by how the brain interprets sensory input and assesses threats

    • This includes the integration of visual, auditory, and contextual factors

  • Memory and Life experiences

    • past experiences with pain can shape how an individual perceives current pain

    • For example, someone who has had traumatic experiences may perceive pain more intensely

  • Emotional state

    • emotions such as anxiety, depression, or stress can amplify the perception of pain, making it feel more intense

• Social Factors

  • Cultural influences

    • different cultures have varying beliefs and attitudes towards pain, which can affect how individuals express, and cope with pain

  • Social support

    • the presence or absence of social support can significantly impact pain perception

    • individuals with strong support systems may experience less pain or cope better than those who are isolated

  • Contextual Factors

    • the environment in which pain is experienced can also influence perception

    • For instance, being in a safe and comforting environment may reduce the perception of pain.

In summary, pain perception is a complex interplay of various factors that go beyond mere physical

(3) Review pain assessment techniques and tools

Pain assessment techniques and tools are essential for accurately evaluating a patient’s pain and guiding effective management strategies

Here are some commonly used methods:

• Self-report scales

  • self-reporting is considered the gold standard in pain assessment

  • Patients provide their own pain ratings, which can be more reliable that observational methods

  • Common self-report tools include:

    • Categorical Rating scale

      • this scale allows patients to categorize their pain into levels such as “No Pain,” “Mild,” “Moderate,” “Severe,” and "Worst Pain Possible.”

      • it simplifies communication about pain intensity

    • Numeric Rating Scale (NRS)

      • patients rate their pain on a scale from 0 to 10, where 0 indicates “No pain” and 10 represents “Worst Pain Possible.”

      • This scale is straightforward and widely used in clinical settings

    • Face Pain Scale

      • Particularly useful for children or individuals who may have difficulty verbalizing their pain, this scale uses facial expressions to represent different pain levels, ranging from “No Hurt” to “Worst Hurt”.

    • Visual Analog Scale (VAS)

      • this tool consists of a straight line, typically 10cm long, where one end represents “No Pain” and the other “Worst Pain Imaginable”

      • Patients mark their pain level on the line, providing a visual representation of their pain intensity

• Observational Techniques

  • In cases where patients cannot self-report (e.g infants, non-verbal patients), healthcare providers may rely on observational techniques

  • These involve assessing behavioural indications of pain, such as facial expressions, body movement, and vocalizations

• Reassessment

  • after administering analgesia, it is crucial to reassess pain levels

  • this typically involves waiting about 20 minutes for the medication to take effect and then using the same pain assessment tools to evaluate the effectiveness of the treatment

  • Documenting the patient’s responses is essential for ongoing pain management

In summary, pain assessment techniques and tools are varied and cater to different patient needs.

They include self-report scales, numeric rating scales, and visual analog scales

Effective pain management relies on accurate assessment, continuous monitoring, and proper documentation

(4) Consider methods of managing pain-pharmacological an non pharmacological

Methods of managing pain can be categorized into pharmacological and non-pharmacological approaches

• Pharmacological methods

  • Analgesics

    • these are medications specifically designed to relieve pain

    • Common types include:

      • non-opioid analgesics, such as acetaminophen & NSAIDs (e.g ibuprofen), which are effective for mild to moderate pain

      • opioids, such as morphine and oxycodone, used for moderate to severe pain

      • adjuvant medications, these include antidepressants and anticonvulsants, which can help manage certain types of pain like neuropathic pain

    • Balanced analgesia

      • this approach combines different medications and techniques to enhance pain control and prevent pain from becoming established

      • it involves selecting the most appropriate route for administration, whether oral, IV, or topical

  • Non-pharmacological methods

    • Positioning

      • adjusting body position can alleviate pain and discomfort

    • Heat/cold packs

      • applying heat can relax muscles, while cold packs can reduce inflammation and numb sharp pain

      • Distraction techniques

        • engaging in activities or using techniques like guided imagery can help divert attention from pain

      • Mobilization

        • gentle movement and physical therapy can improve function and reduce pain over time

        • Additionally, managing associated symptoms is crucial

        • For insance, anti-emetics can help with nausea and vomitting, while laxatives can address constipation, which may arise from analgesic use

In summary, effective pain management often requires a combination of both pharmacological and non-pharmacological methods tailored to the individual’s needs

(5) Introduce the concept of balanced analgesia

Balanced analgesia is a pain management strategy that involves the combination of different medications and techniques to enhance overall pain control

The primary goals of balanced analgesia are to prevent pain from becoming established and to select the most appropriate route for administering analgesics

This approach recognizes that pain can be effectively managed by using non-opioid analgesics, opioids, and adjuvant medications

To implement balanced analgesia effectively, healthcare providers often refer to the WHO Analgesic Ladder, which guides the selection of analgesics based on the severity of pain - mild, moderate, or severe

By tailoring the analgesic regimen to the patient’s specific pain level and individual response, balanced analgesia aims to optimize pain relief while minimizing side effects

Monitoring and Documentation are crucial components of balanced analgesia

After administering analgesia, healthcare providers should reassess the patient’s pain after allowing sufficient time (typically around 20 minutes) for the medication to take effect

This reassessment helps to evaluate the effectiveness of the pain management strategy and to identify any potential side effects

Recording patients’ responses in their notes ensures that there is a clear record of pain management efforts and outcomes, facilitating ongoing adjustments to the analgesic plan as needed

(6) Provide an overview of common analgesics

Common analgesics, also known as painkillers or pain relievers, are medications used to alleviate pain by acting on the peripheral and CNS

They can be categorized based on their mechanism of action an the severity of pain they are intended to treat

• Paracetamol (Acetaminophen)

  • often used for mild to moderate pain relied, paracetamol is a widely used analgesic that works primarily in the CNS

  • it is generally considered safe and is commonly used for headaches, muscle aches, and fever reduction

• Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

  • this class includes medications such as ibuprofen and naproxen

  • NSAIDs are effective for mild to moderate pain and also reduce inflammation

  • they work by inhibiting enzymes involved in the production of prostaglandins, which are chemicals that promote inflammation and pain

• Opioids

  • for moderate to severe pain, opioids such as morphine and oxycodone are often prescribed

  • These drugs act on specific receptors in the brain and spinal cord to block pain signals

  • While effective, they carry a risk of dependence and side effects, necessitating careful management

The concept of “Balanced Analgesia” involves combining these medications and techniques to enhance overall pain control, prevent pain from becoming established, and select the most appropriate route for administration

The WHO Analgesic Ladder is a useful framework for choosing the right analgesics based on the severity of pain, guiding clinicians in providing effective pain management

Diabetic Emergencies

(1) Identify the Chronic complication that arise from DM

Chronic complications of Diabetes Mellitus (DM) can be categorized into microvascular and macrovascular complications, as well as neuropathies and infections

• Microvascular Complications

  These complications primarily affect small blood vessels (capillaries) and include:

  • Retinopathy

    • damage to the retina, which can lead to vision loss

  • Nephropathy

    • kidney damage that can progress to kidney failure

• Macrovascular complications

  These complications involve larger blood vessels and are often associated with cardiovascular diseases, including:

  • Atherosclerosis

    • Hardening and narrowing of the arteries due to plaque build up, increasing the risk of heart attack and stroke

  • Peripheral vascular disease

    • reduced blood flow to the limbs, which can lead to pain and mobility issues

  • Cerebrovascular Disease

    • conditions affecting blood flow to the brain, increasing the risk of stroke

  • Neuropathies

    • diabetes can cause nerve damage, which can be classified into

      • ANS Neuropathy

        • affects involuntary bodily functions, potentially leading to issues such as digestive problems and cardiovascular instability

      • PNS Neuropathy

        • affects the nerves in the extremities causing pain, tingling, and loss of sensation

    • Infections

      • individuals with diabetes are at higher risk for infections due to impaired immune response and poor circulation

Overall, chronic complications of DM can significantly impact quality of life and require ongoing management to prevent progression and associated health issues

(2) Identify what self management is in DM

Self-management in Diabetes Mellitus (DM) refers to the proactive steps individuals take to manage their condition effectively

This includes a variety of practices aimed at maintaining optimal blood glucose levels and preventing complications

Key components of self-management include:

• Regular blood glucose monitoring

  • checking blood sugar levels consistently to understand how food, activity, and medications affect glucose levels

• Foot care

  • regular checks of feet for cuts or injuries, along with scheduled podiatry appointments to prevent complications like infections or ulcers

• Healthy diet

  • adopting a balanced diet that supports blood sugar control, including appropriate carbohydrate intake and nutrient-rich foods

• Weight management

  • achieving and maintaining a healthy weight to improve insulin sensitivity and overall health

• Education

  • gaining knowledge about diabetes management, including dietary education, how to monitor blood sugar levels, and self-care practices

  • Involving family (whanau) in the education process can also self-management helps individuals with diabetes to minimize the risk of complications, such as diabetic ketoacidosis (DKA), which is more common in Type 1 diabetes and can arise from factors like illness, infection, or poor self-management

(3) Be able to educate others on DM

Education on diabetes mellitus (DM) encompasses several critical areas to empower individuals in managing their condition effectively

• Dietary education

  • understanding the role of nutrition is vital

  • individuals are taught about carbohydrate counting, meal planning, and the importance of balanced diets to maintain stable blood sugar levels

• Monitoring blood sugar levels (BSLs)

  • education includes how to properly monitor BSLs using glucometers, recognizing the significance of regular checks, and understanding the target ranges for optimal health

• Self-care

  • patients are educated on self-management strategies, which include recognizing symptoms of high and low blood sugar, adhering to medication regimens, and maintaining a healthy lifestyle through exercise and stress management

• Involving Whanau/Family

  • including family members in education helps create a supportive environment

  • family involvement can enhance adherance to treatment plans and provide emotional support

• Injection sites

  • for those requiring insulin, education on proper injection techniques, rotation in injection sites, and the importance of hygeine is crucial to prevent complications

  • Additionally, understanding diabetic emergencies is essential

  • individuals learn to recognize and respond to conditions such as:

    • Hypoglycemia

      • low blood sugar can lead to symptoms like shakiness, confusion, and fainting

      • Education focuses on how to treat hypoglycemia quickly, often with fast-acting carbohydrates

    • Hyperglycemia

      • High blood sugar may lead to symptoms like excessive thirst and frequent urination

      • Education includes strategies to manage high blood sugar levels

    • Diabetic Ketoacidosis

      • more common in Type 1 Diabetes, DKA can occur due to illness, infection, undiagnosed diabetes, poor self-management, or inadequate insulin dosage

    • Hyperglycemic Hyperosmolar State (HHS)

      • This is a serious condition primarily seen in Type 2 diabetes, characterized by extremely high blood sugar levels

(4) Identify the signs and symptoms, pathophysiology, and treatment on Hypoglycaemia

Signs and Symptoms of Hypoglycaemia:

Hypoglyaemia, or low blood glucose levels, presents with several clinical signs and symptoms, including:

• Diaphoresis - excessive sweating

• Pallor - pale skin appearance

• Confusion and altered mental state - difficulty thinking clearly or changes in behaviour

• Tachycardia - increased heart rate

• Slurred speech and unsteady gait - difficulty speaking and maintaining balance

• Coma - in severe cases, loss of conciousness

• Death - if untreated, it can lead to fatal outcomes

Pathophysiology of hypoglycaemia:

• Hypoglycaemia occurs when blood glucose levels fall below normal, typically below 70 mg/dL

• this can result from excessive insulin administration, prolonged fasting, intense physical activity, or certain medications

• The brain relies on glucose as its primary energy source; therefore, low levels can impair cognitive function and lead to neurological symptoms

• The body’s counter-regulatory mechanisms, such as the release of glucagon and epinephrine, attempt to raise blood glucose levels, but if these are insufficient, symptoms worsen

Treatment on hypoglycaemia:

• immediate treatment for hypoglycaemia involves the rapid administration of glucose

• This can be done through:

  • Oral glucose, if the patient is concious and able to swallow, consuming glucose tablets, sugary drinks, or food high in carbohydrates can quickly raise blood sugar levels

  • Intravenous glucose, in cases of severe hypoglycaemia or when the patient is unconcious, intravenous dextrose (D50) is administered

  • Glucagon injection, for individuals unable to consume glucose orally, glucagon can be injected to stimulate the liver to release stored glucose

In summary, hypoglycaemia is crucial for timely intervention, which primarily involves restoring blood glucose levels to prevent serious complications

(5) Identify the signs and symptoms, pathophysiology, and treatment on Hyperglycaemia

Hyperglycaemia, characterized by elevated blood glucose levels, presents several signs and symptoms

Common indicators include:

• increased urination (polyuria)

• weakness

• fatigue

• blurred vision

• GI disturbances such as nausea and vomitting

If left untreated, hyperglycaemia can progress to more severe conditions like Diabetic Ketoacidosis (DKA) or Hyperglycemic Hyperosmolar State (HHS)

The pathophysiology of hyperglycemia primarily involves insufficient insulin production or action, leading to an inability to effectively utilize glucose for energy

This results in elevated glucose levels in the bloodstream

In individuals with diabetes, factors such as missed insulin doses, illnesses, stress or dietary indiscretions can exacerbate hyperglycaemia

Treatment for hyperglycemia involves several steps.

• Initially, blood sugar levels (BSL) should be checked to confirm hyperglycaemia

• If confirmed, the administration of fast-acting insulin is crucial to lower blood glucose levels

• After 30 minutes, BSL should be rechecked to to access the effectiveness of the treatment

• If necessary, effective subcutaneous (s/c) insulin can be repeated

• Additionally, it is important to investigate and address the underlying cause of hyperglycaemia to prevent recurrence

In summary, hyperglycaemia is marked by specific symptoms, has a clear pathophysiological bases related to prompt treatment with insulin and monitoring to manage blood glucose levels effectively

(6) Identify the signs and symptoms, pathophysiology, and treatment for DKA

Signs & Symptoms of DKA

Diabetic Ketoacidosis (DKA) presents with several key signs and symptoms:

• Dry mouth and thirst, due to dehydration from osmotic diuresis

• Abdominal pain, nausea, and vomiting

  • resulting from metabolic disturbances and irritation of the GI tract

• Restlessness, confusion, and lethargy

  • indicative of cerebral edema or metabolic derangement

• Breath odour of ketones

  • A fruity smell due to the presence of acetone, a ketone body

• Laboured respirations (Kussmaul breathing)

  • a compensatory mechanism to counteract acidosis by expelling CO2

• Urinary frequency

  • increased urination due to high blood glucose levels leading to osmotic diuresis

• Glucosuria and ketonuria

  • presence of glucose and ketones in urine due to high blood sugar levels

Pathophysiology of DKA

• DKA primarily occurs in individuals with Type 1 diabetes but can also occur in Type 2 under certain conditions

• it is characterised by a severe lack of insulin, leading to:

  • increased lipolysis and fatty acid release, resulting in ketone body production

  • Elevated blood glucose due to gluconeogenesis and glycogenolysis

  • metabolic acidosis from the accumulation of ketones, leading to a decrease in blood pH

Treatment for DKA:

• The treatment for DKA involves several critical steps:

  • Fluid replacement, to correct dehydration and restore electrolyte balance

  • Insulin therapy

    • to reduce blood glucose levels and halt ketone production

  • Electrolyte monitoring and replacement

    • particularly potassium, as insulin therapy can cause shifts in potassium levels

  • Addressing underlying causes

    • such as infections or inadequate insulin management

In summary, DKA is a serious condition requiring prompt recognition and treatment to prevent complications

(7) Identify the signs and symptoms, pathophysiology, and treatment for HHS
Hyperglycaemic Hyperosmolar State (HHS) is a serious condition oftern seen in patients in Type 2 diabetes

Signs & Symptoms:

• patients with HHS may present with:

  • elevated blood glucose levels

  • increased urination (polyuria)

  • weakness

  • fatigue

  • blurred vision

  • nausea

• In the early stages, symptoms may be less pronounced compared to DKA, which can lead to delayed diagnosis

Pathophysiology of HHS

• HHS occurs when there is a significant deficiency in insulin, but enough circulating insulin remains to prevent ketogenesis, which is why it is more common in Type 2 diabetes

• The lack of insulin leads to hyperglycaemia, causing osmotic diuresis (increased urination) and dehydration

• This results in a high serum osmolarity, which can lead to severe potential coma

Treatment of HHS

• Management of HHS includes:

  • aggressive fluid replacement to address dehydration and restore normal blood volume

  • Electrolyte monitoring and replacement are also crucial, as patients can become fluid overloaded due to the type of patient and the volume of fluids administered

  • Insulin therapy is initiated to lower blood glucose levels, but it is typically less aggressive than in DKA due to the presence of some circulating than in DKA due to the presence of some circulating insulin

  • Continuous monitoring of blood glucose and electrolytes is essential during treatment

In summary, HHS is characterised by elevated blood glucose and dehydration, with a pathophysiology rooted in insulin deficiency without ketone production. Treatment focuses on fluid replacement and careful monitoring to prevent complications

Deteriorating patient

(1) Recognise the need to identify early signs of deterioration in a patient

(2) Identify the signs of early deterioration

(3) Discuss the importance of following the prompts on the EWS chart

(4) Review the process of EWS escalation

(5) Introduce communication frameworks ISBAR (HB) and SBARR (TC)

(1) Recognise the need to identify early signs of deterioration in a patient

Identify early signs of deterioration in patient is crucial for several reasons

Firstly, early recognition allows for timely intervention, which can significantly improve patient outcomes and potentially save lives

As highlighted, the ability to quickly and accurately detect clinical deterioration is a vital nursing skill that ensures safe, quality care (Crowe, Ewart, & Derman, 2017)

Secondly, subtle changes in a patient’s condition, such as variations in respiratory rate or urine output, may indicate underlying issues even when vital signs appear normal

This emphasizes the importance of clinical judgement and thorough assessment in recognising deteriorating early

For instance, withholding medication like frusemide until a comprehensive evaluation of low blood pressure is conducted can prevent further complications

Additionally, effective reporting mechanisms, such as seeking advise from colleagues or using tools like the Early Warning Score (EWS), facilitate the communication of concerns regarding a patient’s condition

This collaborative approach ensures that appropriate actions are taken swiftly, thereby enhancing patient safety

In summary, the need to identify early signs of deterioration stems from the imperative to provide timely care, utilise clinical judgement effectively, and foster communication among healthcare professionals to improve patient outcomes

(2) Identify the signs of early deterioration

Signs of early deterioration in a patient can be subtle and may not always be reflected in vital signs

Recognising these signs requires clinical judgement and thorough assessment

Here are some key indicators of early deterioration

• Changes in Respiratory rate

  • an increase or decrease in the respiratory rate can indicate that a patient is struggling to maintain adequate oxygenation or is struggling to maintain adequate oxygenation or is experiencing respiratory distress

• Tapering Off of Urine Output

  • a decrease in urine output can signify renal impairment or dehydration, which may be a precursor to more serious complications

• Low Blood Pressure

  • while the excerpt mention that vital signs may be within normal limits, ongoing low blood pressure should prompt further assessment, especially if it is a change from the patient’s baseline

• Subtle behaviour changes

  • Changes in a patient’s level of conciousness or alertness can be also critical indicators of deterioration

• Other non-vital sign indicators

  • factors such as changes in skin colour, temperature, or the presence of new symptoms (e.g pain or discomfort) can also be early signs of deterioration

  • It is emphasized the importance of recognising these signs early to initiate appropriate interventions, such as following the prompts on the EWS chart and escalating care when necessary

  • Effective communication frameworks like ISBAR (identify, situation, background, assessment, recommendation) and SBARR (situation, background,, assessment, recommendation, response) are also crucial for ensuring that concerns about deteriorating are clearly conveyed among healthcare providers

In summary, early signs of deterioration may be subtle and require careful observation and clinical judgement, highlighting the importance of ongoing assessment and communication in patient care

(3) Discuss the importance of following the prompts on the EWS chart

Following the prompts on the EWS chart is crucial for several reasons:

• Early detection of deterioration

  • The EWS chart is designed to help healthcare professionals recognise early signs of patient deterioration

  • by systematically assessing vital signs and other clinical parameters, staff can identify patients at risk of serious comlications

  • Early intervention can significantly improve patient outcomes

• Standardized communication

  • The EWS chart provides a standardised method for documenting and communicating a patient’s status

  • this consistency is vital in a healthcare setting where multiple providers may be involved in a patient’s care

  • Using a common framework, such as ISBAR or SBARR, ensures that critical information is coveyed clearly and efficiently

• Escalation pathway

  • the EWS chart outlines a clear escalation pathway for responding to identified risks

  • Following the prompts ensures that appropriate actions are taken based on the patient’s score, which may include notifying senior staff, activating a rapid response team, or transferring the patient for further evaluation

  • This structures approach minimizes delays in care and enhances patient safety

• Documentation and Accountability

  • properly documenting responses to EWS alerts is essential for accountability and continuity of care

  • It provides a record of the clinical decision-making process, which can be reviews later for quality assurance and improvement

  • This documentation also serves as a communication tool among team members and help’s in tracking the patient’s progress

• Reducing In-Hospital Mortality

  • it is indicated that the in-hospital mortality rate for patients rapid response activation is approximately 25%

  • by diligently following the EWS prompts, healthcare providers can potentially reduce this mortality rate by ensuring timely and appropriate interventions

In summary, adhering to the prompts on the EWS chart is vital for early detection of patient deterioration, effective communication, structured escalation of care, thorough documentation, and ultimately improving patient outcomes and safety

(4) Review the process of EWS escalation

The process of EWS escalation involves a systematic approach to identifying and responding to signs of patient deterioration based on their EWS.

Here’s a succinct breakdown of the process

• Assessment of EWS

  • the patient’s vital signs are monitored and scored using the EWS chart

  • Scores range from 1 - 10+, with higher scores indicating more severe deterioration

• Action based on EWS score

  • EWS 1 - 5

    • manage pain, fever, or distress

    • increase the frequency of vital signs measurement and inform the shift coordinator and Resident Medical Officer (RMO)

  • EW 6 -7

    • if out of hours, an RMO assessment is required within 60 minutes

    • Document the plan, including interventions and review timeframes

  • EWS 8 - 9

    • immediate RMO assessment is necessary, along with a Senior Medical Officer (SMO) review within 30 minutes

    • Early involvement of the Duty Nurse Manager (DNM) may be required especially if the patient in likely to deteriorate rapidly

  • EWS 10+ or any vital sign in the blue zone

    • call 7777 for rapid response, stating "‘rapid response’ and providing your location

    • Immediate life support measures for airway, breathing, and circulation are critical

• Documentation and Communication

  • throughout the escalation process, it is essential to document all actions taken and communicate effectively using frameworks like ISBAR or SBARR

  • this structured approach ensures timely intervention and enhances patient safety by addressing potential critical conditions before they escalate

(5) Introduce communication frameworks ISBAR (HB) and SBARR (TC)

The communication frameworks ISBAR and SBARR are structured methods used in healthcare to facilitate effective communication among healthcare professionals, particularly during critical situations

• ISBARR (HB) stands for

  • Identify; clearly state who you are, your role, and the patient you are discussing

    • This sets the context for the conversation

  • Situation:

    • describe the current situation, including the patient’s condition and any immediate concern

    • for example, “The patient has an early warning score indicating potential deterioration”

  • Background

    • provide relevant background information about the patient, including medical history, recent changes in condition, and treatments that have been administered

  • Assessment

    • share your assessment of the situation including vital signs and any other relevant clinical findings

  • Recommendation

    • make a clear recommendation for what you believe should happen next, such as requesting a review by a senior nurse or a rapid response team

• SBARR (TC)

  • is a variation that emphasizes a slightly different structure but follows a similar concept:

  • Situation

    • similar to ISBAR, start with the current situation and the reason for the communication

  • Background

    • provide the necessary background information to give context to the situation

  • Assessment

    • discuss your assessment of the patient’s condition

  • Recommendation

    • conclude with a recommendation for action or further assessment

• Both frameworks are designed to enhance clarity and ensure that critical information is communicated effectively, especially in urgent situations like a potential cardiorespiratory arrest

• They help streamline communication, reduce the risk of misunderstandings, and ensure that all team members are on the same page regarding patient care

• In practice, using these frameworks can lead to improved patient outcomes by ensuring timely interventions and fostering a culture of safety and teamwork in healthcare settings