Nursing Practice

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Questions Received:

  1. My urologist ordered an ultrasound on my testicles and prostate. I was a little embarrassed. Do these technicians get use to this type of thing?

  2. What is the nursing care preoperatively of a patient having laparotomy?

  3. What is the post operative care of a patient having a lower anterior bowel resection?

  4. Is there a formula for calculating the rate of flow that an infusion or a blood transfusion should be set at?

  5. I know it is a broad topic - but I am to prepare a workbook on INTRAVENOUS INFUSION and ANAESTHETIC and would appreciate any information which you have.

  6. I work within an endoscopy unit in the west coast of Scotland. We are currently reviewing our practice regarding cystoscopy procedure. Our discussion : we use cystoscopes that are disinfected not sterile yet we place it on a sterile surface, handle it with sterile gloved hands. Is this necessary? Would non-sterile gloves be sufficient? Does the work surface need to be sterile? Can it be clean ( we use alcohol wipes for work surface for gastrointestinal procedures - 70%). Do we continue to treat it as a sterile procedure? If so why do we not use a sterile scope (we are told - disinfection is adequate). Please help as we are going round in circles.

  7. How would a nurse stand legally if drugs which she had drawn up for a Doctor were then given to a patient by that Doctor and resulted in an error occurring, eg: Doctor mistakenly giving wrong dose, medication etc? I am advised presently that the fact I have assisted the Doctor by preparing the drug for adminstration is neither here nor there. He is ultimately responsible for checking himself what I have prepared and the dose. Is this so? Would it be so straight-forward in a court of law? Bear in mind we are British. Not subject to litigation as often or as easily as our American colleagues.

  8. Are mercury weighted intestinal tubes, such as the Miller-Abbott, Harris, or Cantor tubes used any more? If so are they substituting something else for the mercury?

Responses:


My urologist ordered an ultrasound on my testicles and prostate. At the outpatient clinic a female technician and another female in training performed the test. The trainee held my penis out of the way with a gloved hand. She simply held it against my lower stomach with the palm of her hand. Is this normal? Also when they inserted the probe into my anus for the prostate exam I got an erection.Is this normal? I was a little embarrassed. Do these technicians get use to this type of thing?

11th February 1999

Anyone working in a field which involves intimate contact with patients would be expected to convey sensitivity and respect for the patient's feelings. Aside from the possession of technical expertise patients have a right to expect that due care and concern will be given towards their need for privacy and comfort, both physically and psychologically.

Experiencing an erection whilst undergoing a rectal examination to determine prostatic function is not altogether unusual, particularly in view of the fact that the whole procedure also involved handling the genitalia. Again, people working as either doctors, nurses or technicians are aware that such a response can be inadvertently provoked when they are performing such procedures. For a patient this can be embarrassing but it is important to realise that the staff are not embarrassed, and accept that such reactions can quite easily occur.

The only part in the procedure that I can think of which might have eased your embarrassment would have been, if the technician had asked you to hold your penis away from the area being examined.


What is the nursing care pre-operatively of a patient having laparotomy?

16th March 1999

A Nursing Model appropriate to a particular practice setting would be used. The assessment, planning and nursing intervention strategies would depend on whether the person was about to undergo emergency laparotomy, or whether the surgery was planned in the sense that the person had been admitted from the Waiting List.

The general preparation would be the same as for any other operation requiring the administration of a general anaesthetic. Additional points to consider would be:

Psychological Care (core areas):

Provide specific information about the procedures that are to be conducted on the person both before and after surgery. Check that informed consent has been given, and that the person understands what has been said. Give preoperative teaching regarding the activities that the person can aim to perform after the immediate pre-operative period, e.g. deep breathing exercises, movement of limbs, operating a patient-controlled analgesic pump. Provide information regarding the anticipated day of operation and expected length of stay.

Physical Care (core areas):

checking namePrescribed pre-operative drugs would be administered. Normally these consists of an opioid analgesic, a substance to block parasympathetic stimulation and dry up secretions e.g. Atropine, and/or a benzodiazepine e.g. diazepam or midazolam. Patients should be warned not to get out of bed once these substances have been given. The nurse call-bell will be placed within the patient's reach. The pre-operative check list will now be completed.

 

 

 

Suggested Reading

Wicker, P. (1995) Pre-operative visiting, making it work. British Journal of Theatre Nursing, 15(7), 16-19.


What is the post operative care of a patient having a lower anterior bowel resection?

16th March 1999

Post-operative aim: to achieve a safe and uncomplicated transition from a period of high dependency to one of independence.

A Nursing Model which is recognised and approved by the nursing team would be implemented. Care for the patient would require a nursing history and assessment to be undertaken. Care planning, implementation and evaluation would be integral to the framework for care.

Within the Recovery Unit:

Communication - clear and concise information from the Theatre Nurse handing over the patient will be essential, particularly in relation to:

It will be important to communicate the person's care details in a quiet and controlled manner, keeping in mind that hearing is the first sense to return. Sensitivity concerning the patient's potential ability to hear, but not respond, is an important consideration.

Breathing - maintenance of the airway until the full return of the patient's protective reflexes will be paramount. Observing the respiratory rate, level of tissue perfusion (as revealed by changes in skin colour) and administering prescribed oxygen are key considerations. Familiarity with the equipment to deal with any respiratory complications will be essential. When the person is able to maintain their own airway observations continue. Listening during inspiration and expiration, feeling expired air against the back of the hand and observing colour are valuable checks. Oximetery will indicate the degree by which oxygen therapy is being effective. Naloxone Hydrochloride will be kept nearby and, if necessary, administered according to the instructions of the Anaesthetist.

Monitoring/evaluating (to influence care planning) - the patient will be in a degree of shock, both hypovolaemic and neurogenic. Monitoring reveals the degree of shock the person is in and the extent to which medical and nursing interventions are being effective. The pulse and blood pressure are recorded regularly e.g. 5-10 minutes initially, the frequency lessening in response to improvements. A rising pulse rate and falling blood pressure are indications that shock is progressing and urgent nursing/medical intervention is required. Drainage from wound drains e.g. vacu-drains will be carefully observed, excessive drainage will be reported. The patient's abdominal wound will periodically be carefully checked for signs of leakage.

Rest and sleep - it will be necessary to ensure that uninterrupted rest can be achieved. Communicating with the patient to determine the degree by which they are pain free and not experiencing discomfort is essential. A Pain Score Chart will be used and prescribed opiates given accordingly. Monitoring the patient's response to these preparations will be essential.

A Patient Controlled Analgesic device may be in use. Regular checks will be conducted on infusion pumps to ensure that these are working correctly.

Reorientating the person is essential and giving information to lessen stress and anxiety should help the accomplishment of psychological and therefore physical rest. (Point to ponder: To what extent does rest contribute towards healing?)

Eating and drinking - as the person will have developed paralytic ileus nothing will be given by mouth until peristalsis resumes. Sips of water only, may though be permitted. The stomach will be kept empty by the use of a naso-gastric tube which will be regularly aspirated and/or kept on free drainage. The amount of aspirate will be regularly recorded. Intravenous fluids will be administered as prescribed. A blood transfusion may be in progress, in which case transfusion observations will be taken and recorded. All fluid administered intravenously must run to time e.g. 1,000ml. over 8 hrs.= 41drops per minute. Anti-emetic preparations e.g. Prochlorperazine (A phenothiazine-related preparation) 12.5mg. I.M. 4-6 hrly. will, if necessary, be administered and the patient's response observed and recorded.

Eliminating - fluid output will be recorded. The urinary output during the first 6-12 hrs. postoperatively may be reduced in response to the stress of surgery - anti-diuretic hormone (ADH) release from the posterior pituitary gland is increased. The ADH acts on the distal convoluted tubules making these less permeable to water, and as a result less urine is produced. As the patient's state of hydration improves, less ADH is produced and an improved diuresis occurs. Signs of worsening oliguria or the development of anuria must be immediately communicated to the medical team.

The patient will remain in the Recovery Unit until both the Anaesthetist and the Nursing Team decide that the patient can return to the ward. The overriding considerations are that the patient is physiologically stable, pain free and able to maintain their own airway. The Recovery Room Nurse will then carefully hand the patient over to the ward Nursing Team.

Within the Ward:

In the ward the care is to a certain extent an extension to that which was established in the Recovery Unit.

Following a period of rest, support and monitoring, the patient is gradually encouraged to become a partner in their care. Effective pain control and anti-emetic measures should help towards the attainment of early mobilisation, and therefore lessen the risks associated with enforced rest.

Two final points to consider:

Reading


Is there a formula for calculating the rate of flow that an infusion or a blood transfusion should be set at?

31st March 1999

The doctor will have prescribed either an infusion or a transfusion for a patient to receive and the duration (the time over which the volume should be administered e.g. usually 8 hours for a litre (1,000 ml) or 4 hours for a half-litre (500 ml) ). One unit of blood has a volume of 450 ml.

The administration set selected will depend on whether an infusion or a transfusion is to be administered. For a crystalloid solution such as normal saline or dextrose saline a solution set will be used. These normally deliver 20 drops per ml. For a colloid solution e.g. blood, a blood administration set will be used and these deliver 15 drops per ml. However, it is always important to read the manufacturer's instructions.

The total volume is converted into drops. Therefore, if a crystalloid solution of 1,000ml. is prescribed and the administration set delivers 20 drops per ml, then in 1,000 ml there will potentially be 20,000 drops.

The duration is converted into minutes. If this is 8 hours then multiplying this by 60 = 480 minutes. The total number of drops in the given volume - 20,000 - is then divided by the duration - 480 minutes. This gives a figure of 41. Therefore the flow control rate will be set to deliver 41 drops per minute.

When running an infusion or a transfusion to the prescribed time it is very important to minimise the risk of either fluid overload or a shortfall occurring. Also once the oral route is bypassed for fluid administration the person undergoing the procedure will not be able to say when they have had enough, as they would if the fluid were to be offered by mouth.

Fluid Prescription Sheets normally show the rates at which administration flow control devices should be set. However, it is useful to have the above simple formula in mind to double check ... after all printing errors can sometimes occur!


I know it is a broad topic - but I am to prepare a workbook on INTRAVENOUS INFUSION and ANAESTHETIC and would appreciate any information which you have.

8th April 1999; revised 26th April 1999

Intravenous Infusion - Nursing Perspectives

Preparation of the patient/client

Psychological - an explanation of the procedure, including rationale: what the person can do to enable the procedure to run smoothly, what they should avoid doing, and roughly how long the infusion will be in progress. The potential effects of the procedure on the patient's relatives should also be taken into account. For example, parents might be alarmed by the fact that their child is attached to an intravenous infusion. psychological - an explanation of the procedure, including rationale: what the person can do to enable the procedure to run smoothly, what they should avoid doing, and roughly how long the infusion will be in progress. The potential effects of the procedure on the patient's relatives should also be taken into account.

HandFor example, parents might be alarmed by the fact that their child is attached to an intravenous infusion. psychological - an explanation of the procedure, including rationale: what the person can do to enable the procedure to run smoothly, what they should avoid doing, and roughly how long the infusion will be in progress. The potential effects of the procedure on the patient's relatives should also be taken into account. For example, parents might be alarmed by the fact that their child is attached to an intravenous infusion.

Physical - preparation of the skin surface over which the cannula is to be sited (normally over the back of the hand or forearm). physical - preparation of the skin surface over which the cannula is to be sited (normally over the back of the hand or forearm). physical - preparation of the skin surface over which the cannula is to be sited (normally over the back of the hand or forearm).

This may involve removal of any hair as adhesive tape should not be applied over body hair. The doctor is normally the person responsible for inserting an intravenous cannula. However, nurses are beginning to take on this procedure as an extended role in the U.K. A local anaesthetic or topical anaesthetic cream (eg: EMLA or Ametop) may be offered to ease the pain which cannulation can produce.

 

 

 

Safety

The following checks need to be made:

Monitoring

Equipment

The procedure involves the use of:

N.B. The procedure requires an aseptic approach and appropriate measures to reduce the risk of contamination must be upheld throughout.

Solutions

Anaesthetics - Nursing Perspectives

Nursing practice frequently involves the care of patients who have to undergo procedures which necessitate the use of a general anaesthetic. Nurses are involved in caring for such people in the pre-operative, intra-operative and post-operative phases. The provision of such care requires skill and precision. Nurses not only have to administer quite potent drugs during the pre- and post-operative phases, they need also to possess a comprehensive knowledge of the therapeutic and non-therapeutic effects of these preparations. In addition, a knowledge of the drugs administered by the anaesthetist is required.

Psychological Preparation

It is essential that the patient is given as much information as is thought necessary beforehand. Informed consent must be obtained and a consent form signed. Usually this is carried out by the doctor. The age at which consent may be given is sixteen (within the U.K.). For people below this age the consent of the parent or guardian must be obtained. Legally, however, those under 16 may be deemed responsible to give consent. It is important that the process of information giving and signing of the consent form is completed before any pre-medication is administered.

Premedication

Not all operations necessitate the administration of a premedication. Previously premedication was commonplace but practice is changing. Although for the majority of operations anaesthetists still prescribe a premedication, there are occasions when the patient may be allowed to choose. In some instances the pre-medication may be given on induction. Drugs from the following groups may be prescribed:

Drugs such as Diazepam and Morphine bring about changes in the person's mental state. As a result the patient's anxiety can be lessened and a state of calm induced. Morphine will also provide pain control, particularly during the intraoperative period. The anticholinergic drug Atropine may be prescribed. This preparation acts on the parasympathetic nerves supplying the salivary glands, peventing secretion. It is important to protect the person from noise and nuisance after such preparations have been given. Ideally the person should arrive in the Anaesthetic Room in a quiet, calm and fairly relaxed state.

Anaesthetics

Anaesthesia produces a state of insensibility. This state of insensibility must be controllable and reversable. The administration of anaesthetic agents produces: unconsciousness, analgesia and if necessary muscular relaxation.

Recovery

The effects of the anaesthetic agents are reversed. The anaesthetic gases and vapours are switched off and the patient breathes an oxygen enriched mixture. Neostigmine may be given to reverse the effects of non-depolarising muscle relaxants. Naloxone hydrochloride may be given to treat respiratory depression if this emerges as a result of opioid administration. The drug Flumazenil may be given to reverse the effects of benzodiazepines. Protection from pain is mandatory also at this stage and post operative opiate administration together with the regular administration of anti-emetics begins. Airway protection, monitoring vital signs and administering prescribed drugs together with maintaining infusions/transfusions are all important nursing priorities at this stage. Frequently local anaesthetic and regional techniques such as epidural infusions or patient controlled analgesia (PCA) are used to achieve post-operative pain relief.

Bibliography


I work within an endoscopy unit in the west coast of Scotland. We are currently reviewing our practice regarding cystoscopy procedure. Our discussion : we use cystoscopes that are disinfected not sterile yet we place it on a sterile surface, handle it with sterile gloved hands. Is this necessary? Would non-sterile gloves be sufficient? Does the work surface need to be sterile? Can it be clean ( we use alcohol wipes for work surface for gastrointestinal procedures - 70%). Do we continue to treat it as a sterile procedure? If so why do we not use a sterile scope (we are told - disinfection is adequate). Please help as we are going round in circles.

13th April 1999

Cystoscopes are precision optical instruments and are not robust enough to be sterilised. Therefore chemical disinfection (for example with glutaraldehyde) becomes the only practical way to ensure that the risk of pathogenic contamination of the urinary tract is kept to an absolute minimum. Understandably, this constraint can lead practitioners to question the justification behind the use of sterile gloves when handling a cystoscope, and the need to provide a sterile surface.

One way of viewing the rationale behind this approach is to think about the consequences of contamination. Should contamination occur following the usual disinfection procedure for cystoscopes and the handling of the scope with sterile gloves combined with the use of a sterile field, then the disinfection procedure would be the only likely source. If contamination were to occur under circumstances where clean gloves and a clean field had been the practice then these two areas would also have to be considered.

Therefore it is suggested that by providing the ultimate environment (sterile field and sterile gloves) the potential risks of contamination are reduced. As a result, the patient/s are then offered the best possible standard of care.

Suggested reading: Decontamination of Urological Equipment, Interim report of the Standing Committee on Urological Instruments. British Journal of Urology, 71. (5 September 1993)Suggested reading: Decontamination of Urological Equipment, Interim report of the Standing Committee on Urological Instruments. British Journal of Urology, 71. (5 September 1993)

We would like to thank Mrs. Tracey Cooper, Infection Control Nurse, Royal Devon & Exeter Healthcare N.H.S.Trust, Wonford, Exeter, Devon EX2 5DW for her help in compiling this response.


How would a nurse stand legally if drugs which she had drawn up for a Doctor were then given to a patient by that Doctor and resulted in an error occurring, eg: Doctor mistakenly giving wrong dose, medication etc? I am advised presently that the fact I have assisted the Doctor by preparing the drug for administration is neither here nor there. He is ultimately responsible for checking himself what I have prepared and the dose. Is this so? Would it be so straight-forward in a court of law? Bear in mind we are British. Not subject to litigation as often or as easily as our American colleagues.

12th May 1999

The following is a personal view, based on the limited information given and my experience as a nurse. It is not intended to act as a substitute for professional advice either from a professional organisation or a member of the legal profession.

Although the nurse did not administer the drug she/he did draw the preparation up ready for administration and as such played a 'key' part in the procedure. Under these circumstances it is assumed that the nurse is competent in carrying out the stages of preparation and that she/he understood the prescription and possessed knowledge of the drug and the dose. Both the nurse and the doctor are under a duty to ensure that the correct drug, at the correct strength, is given to the correct patient at the correct time and by the correct route. Although the drug was handed across by the nurse to the doctor for him/her to administer one would expect the nurse to prepare the drug correctly, and that both parties would jointly go through the regime of checks already stated before administering the drug. Not to do so could be construed as acting unreasonably and therefore I think the nurse may be culpable.


Are mercury weighted intestinal tubes, such as the Miller-Abbott, Harris, or Cantor tubes used any more? If so are they substituting something else for the mercury?

6th November 1999

Weighted intestinal tubes for parenteral nutrition were developed to facilitate duodenal intubation and to reduce the risk of aspiration into the bronchi. The Miller-Abbot tube which you refer to has not been used in my experience (which has been confined to just three District General Hospitals in the U.K.) since the early 1960's. The Miller-Abbot tube was designed by two American physicians, Thomas Miller (1886-1981) and William Abbot (1902-1943). This is a double lumen tube used as method for achieving intestinal decompression (Mosby 1998, p.1035). The Harris tube, developed by an American surgeon Franklin Harris (b.1895) is a mercury weighted tube used for gastric and intestinal decompression. The amount of mercury situated in the soft bag which surrounds the tube varies from 2-5ml. according to age, size and condition of the patient. The Cantor tube was designed by Meyer Cantor, an American physician (b.1907). This is a double lumen tube which has a rubber bag at one end and is used to relieve obstruction in the small bowel (Mosby 1998, p. 256). I have not encountered either of these in practice.

The pre-packed disposable Ryle's type of naso-gastric tube is now the more common tube used for achieving gastric aspiration and facilitating decompression within the lower gastrointestinal tract. Given the potential hazards of mercury use, other materials such as tungsten tend to be used now if a weighted tube is required (Ugo, Mohler, and Wilson, 1992).

Comparisons have been made between weighted and unweighted tubes, but a consensus has not yet been reached on their relative merits. For example, Jimenez et al (1993) reported that weighted tubes showed greater effectiveness in duodenal intubation rate and the time they remained in the body, while Silk et al (1987) and Levenson et al (1988) found no advantage of weighted tubes over unweighted tubes. Lord et al (1993) obtained better transpyloric passage with unweighted tubes.

Several methods for the post-pyloric positioning of enteral feeding tubes have been evaluated. Tubes are often introduced by nursing staff without visual or radiological control. A prospective study by Christen and Hess (1996) demonstrated that this method suffices in most instances, while checking by an experienced person adds to safety. They suggest that radiological control can be safely limited to cases in which there was a problem in positioning the tube or when the clinical control was unclear. Endoscopic techniques are being used increasingly (Kim, 1985; Gowen et al, 1987; Rees et al, 1988; Snyder et al, 1990; Mathus-Vliegen et al, 1993; Lo and Shinya, 1993; Kwauk et al, 1996). In a new technique, Gabriel et al (1997) modified a standard nasoenteral feeding tube by inserting a small magnet into the distal tip. The tube could then be guided into position by an external magnet placed over the abdomen. Transpyloric placement was achieved in the majority of cases.

Metoclopramide improves gastric emptying, and has been given to patients prior to tube insertion to facilitate passage of the tube through the stomach and into the duodenum (Whatley et al, 1984).

References

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