Tops Tips for Staying Cool

As you have probably noticed, we’re currently experiencing a bit of a heatwave at the moment! This may mean ice cream and sunbathing for some, but for us student nurses it isn’t much fun! From stuffy uniforms and buses hotter than hell, to rushing around Image result for warm weatherensuring patients are hydrated whilst being dehydrated yourself.

So what the the top tips for staying cool in a heatwave?

  1. Sun cream!! Especially if you’re on community or commute via walking/cycling.
  2. Keep hydrated***. It’s obvious, and we all harp on about it, but the day will drag more and the heat will hit you harder if you don’t keep drinking cold water or juice. Make sure you have a bottle or jug nearby to remind you, or drink with your Image result for patient drinking waterpatients so you both get the benefit!
  3. Don’t over-exert yourself. You are the most important person to take care of in your life! Make sure you take regular little breaks for drinks + a sit down. I know it can be hard, but you’re no use to your patients if you aren’t on top form!
  4. Change into your uniform when you get to placement. It prevents you starting your shift in a sweaty mess, and allows your body to cool down on your way home.
  5.  Avoid too much caffeine. I know this sounds barbaric (I can’t survive a shift without coffee) but caffeine is a diuretic. That means you’re going to the toilet more, which leads to more water loss. Try not to overdo the coffee intake!
  6. Try and get some sleep! Nothing is going to make a hot day longer + harder than lack of sleep. If you need a fan, get one! I know I couldn’t cope without mine.
  7. ***Know the signs. Dehydration can be bad news, whether its staff or patients. Make sure you know the signs (headache, dry mouth, not urinating a lot) and keep an eye out. Let someone know if you or a patient is suffering.

Have you been coping with the heat? Send us any tips/tricks via email, Facebook or Twitter !

 

 

Pressure Sores 101

One of the most common nursing buzzwords- pressure sores (AKA pressure ulcers). They can be developed by anyone, and in a wide range of places on the body. As nurses (student or not!) it is our responsibility to report, treat and prevent them.

What is a pressure sore?

A pressure sore is an area of skin that has been deprived of oxygen, due to continuous pressure. This prevents the area of skin getting enough blood, causing the skin to “blanch” (become white due to lack of blood flow). This can then develop into varying degrees of tissue damage; ranging from grade 1 to 4 depending on the severity (NHS Stop the Pressure, 2009).

Grade 1-  skin is intact but blanching, may be some heat/oedema as well 

Grade 2- partial thickness skin loss, looks like an abrasion or a blister. 

Grade 3- full thickness skin loss, some fat may be visible. Possible ‘undermining’ or ‘tracking’ as there is usually depth, depending on the location. This depth can sometimes be covered by slough, which needs to be removed before proper grading can take place. 

Grade 4- full thickness tissue loss, with exposed bone or tendon. There tends to be undermining or tracking, depending on the location. 

Where do they crop up?

Areas that have a hard bony prominence are at risk of pressure sores. This is because they have the least amount of skin protecting itself.

What factors lead to a higher risk of pressure sores?

There are many factors that increase the risk of pressure sores:

  • poor circulation – this could be caused by kidney problems, heart diseases or diabetes.
  • reduced/no mobility- it doesn’t have to be long term! even short term loss of mobility (e.g. after an operation) leads to a pressure ulcer risk.
  • friction- this is where good practice comes in. People who transfer frequently between bed-hoist-chair or just bed-chair, and being moved up/down a bed are at risk. This is why we use slide sheets!

How can they be treated?

  • regular re-positioning/ turns are vital! This helps distribute the pressure, and reduce the risk of the pressure sore from getting worse. You must assess whether the patient is able to do this themselves, or if they require help. Asking the patient (if they have capacity) is always best.
  • pressure relieving devices such as airflow mattresses or pressure cushions can be obtained through physiotherapists, occupational therapists, some trusts require nurses to send the referrals (depends on the area).

  • regular cleaning of the area. Special washes can be used such barrier creams or sprays like ‘Sorbaderm’. This is especially useful for pressure sores on the buttocks/sacrum as they are subjected to lots of moisture.
  • dressings! There are a wide range of dressings which can be used on pressure sores, those that have foam are good for extra protection.

 

How can they be prevented?

Similar to the above treatment! Encourage your patient to mobilize frequently (if possible) and explain the reasons why. Those who are at risk will be identified by their Waterlow Score (10+). If in the community and the patient has carers/relatives helping with their care, speak to them and ask them to update you on any concerns re: pressure sores. Completing bodymaps whenever a new patient arrives and update it regularly is also important. This allows you to assess the patient’s skin integrity, and keep an eye on any possible developments.

 

If you have any ideas for another ‘101 guide’, please get in contact via facebook, twitter or email us on enhancingplacement@gmail.com.

 

 

Election time: Will Britain vote for more zombie capitalism?

Left in New Zealand

Despite Jeremy Corbyn’s courageous fightback in the lead up to this election and a slim chance of victory, I suspect by the morning of June 9th the population of the UK will have walked bewilderingly into 5 more years of Tory rule. A further half-decade of class warfare in which the 1% will continue to beat the peasants into submission with their bonus cheques. We can expect more cuts to public services, further privatisaton of the NHS and ever widening inequality. Never fear, we will be saved by Theresa May as she has declared they will form a ‘strong and stable’ government. The question must be asked, for whom? Surely not the growing amount people who are now forced to use foodbanks just to get by. Certainly not the sick and disabled who have seen their benefits slashed, along with the unemployed. Theresa May I suspect won’t be fighting…

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Maintaining Friendships Old And New

I moved into halls for the first year of university despite already living in Manchester (well, Greater Manchester). I felt ready to gain some independence by ‘flying the nest’ and wanted to be within walking distance of university. When I lived with my mum before university I was only less than twenty miles away from the main campus so my friends from home who I used to live super close to aren’t incredibly far from my accommodation. The nursing course can get pretty hectic at times; more often than not all you want to do when you get back from placement is have a good kip!

Seeing my friends from home can be tricky to plan, to be honest, especially seeing as they have commitments like work and studying just like I do and it’s not just a ten minute journey involved in meeting up. I probably don’t tell them enough that I miss them, but I really do, and I really look forward to going home to meet up with my friends or having them stay over at my flat. Seeing my friends from home is so good for helping me stay grounded and true to my incredibly Mancunian roots and it reminds me of a big reason why I’m doing this course. I really hope I can make the people I care about and who care about me proud. If you don’t have the opportunity to meet up with your friends from home very often you’ll understand that the time you spend together is golden and you’ll appreciate it all the more. I’m so, so fortunate to have maintained friendships with such a brilliant bunch of people even after all these years.13151090_226356241076122_2131036156_nI enjoy spending time with the friends I’ve made on my course too, as I think we have a good balance between chatting about nursing as well as unrelated things. We’ll talk about what skills we’ve been learning on placement and helping each other stay motivated when writing assignments by offering suggestions of resources to look at and just offering a pep talk sprinkled with the essence of ‘as a fellow student nurse, I really know how you feel’ then five minutes later we’ll be having a conversation about something like make-up or food. I’m so, so fortunate to have made such a brilliant bunch of friends at uni.

My advice to anybody studying on a course that keeps you super busy (ring any bells?) would be to appreciate and make time for your friends from home whilst still being open to making new friendships at uni. Your friends from home will be glad that you’re enjoying yourself and have support for when they can’t physically come to see you. Believe me, you’ll have no idea how you would have made it through uni without your friends – old and new.

 

‘Tools of the Trade’: Adult Field

Preparing for your first placement and feeling uncertain about what assessment tools you might encounter? Have a browse through this post where we’ve collated some assessment tools and tips you might find useful, with links to the sources in the title. If you’ve not seen it already, you can also find some useful information in our top tips album on our Facebook page. Have a look at the Mental Health tips and tools here, Child Field and Midwifery specific posts to follow soon!

Below are a selection of assessment tools in alphabetical order, remember that all risk assessment scoring tools are simplified to some extent and scoring may be subjective. Therefore it’s important to use them in the correct setting alongside your own clinical judgement, never underestimate your gut feeling and if you have any concerns about a patient, speak up!


Bristol Stool Chart

Also known as the Meyers scale, the pictures and descriptions on the Bristol stool chart will help you assess stool samples. Stool charts are often in place if a patient is being barrier nursed with infective diarrhoea. Colour, presence of blood or mucus are also important things to look out for when assessing stool samples.

Image result for bristol stool chart

ECOG Performance Status Score

Used in Oncology to assess disease progression and how this impact’s on a patient’s activities of daily living. Created by the Eastern Cooperative Oncology Group, this 0-5 scale is something you will come across on any oncology placements, familiarising yourself with the descriptions of these categories will help you understand the impact of performance status on patient’s day to day experiences.

Grade 0 : Fully active, able to carry on all pre-disease performance without restriction
Grade 1 : Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work
Grade 2 : Ambulatory and capable of all self care but unable to carry out any work activities, up and about more than 50% of waking hours
Grade 3 : Capable of only limited self care, confined to bed or chair more than 50% of waking hours
Grade 4 : Completely disabled, cannot carry on any self care, totally confined to bed or chair
Grade 5 : Dead

Frailty Assessment

There are many different tools used to assess frailty, but the PRISMA 7 checklist below is perhaps the easiest to use as an informal prompt to identify at risk patients. It has been used in a variety of research studies on frailty to identify disability, a score of >3 indicates frailty.

1- Older than 85 years?
2- Male?
3- Any health problems which limit ADLs?
4- Requiring help on a daily/regular basis?

5- Housebound due to health conditions?
6- In case of need can they count on someone close to them?
7- Regular use of a stick, walker, wheelchair or other aids to get about? 

Other red flags to look out for include is a patient lives alone or if they are a carer for another person. Frailty can impact on discharge planning and is useful to consider when planning interventions to avoid future hospital admissions. There are also other useful resources and information from Age UK and the British Geriatrics Society.

Glasgow Coma Scale (GCS)

GCS is used to assess a patients consciousness level, primarily in acute areas such as A&E or ICU. Assessing a patient’s GCS can be complex and involves three categories: eye opening, verbal response and best motor response. After checking for factors that might impede the patient’s ability to respond, each of the three criteria are assessed through observation and stimulus and are then rated according to the highest observed response. Unless you’re working in a placement are which uses the GCS assessment frequently where you can be taught how to use it correctly, it’s probably best to use an alternative.

AVPU is a similar tool to rapidly and simply assess your patient, it is based on the same three categories as the GCS and looks for the best response, working down from best to worst A-U to avoid unnecessary tests.

A- Alert
V- Alert to Voice
P- Alert to Pain
U- Unconscious 

If a patient is fully awake and can spontaneously open their eyes and has control of motor function they are Alert, although they do not necessarily have to be orientated. Patients who are alert to Voice will make some form of response in any of the three categories when you speak to them. If alert to Pain, a patient with some level of consciousness will respond to painful stimuli with any of the same categories of response and fully unconscious patients will form any response to any of the above.

Early Warning Score (EWS)

In practice you may come across some variations of the EWS (Paediatric (PEWS), Modified (MEWS), National (NEWS) and Modified Early Obstetric Warning Score (MEOWS)), for this reason the scores and corresponding clinical observations haven’t been included in this post.

Ensure you use the tool that has been selected for use in your clinical area as there are variations between them according to specific patient type or to support best evidence based practice. To begin with don’t worry about remembering the exact scores for each observation, the scores are printed on observation charts and care plans, all you need to recognise is when observations are abnormal and escalate it.

When taking a full set of observations, a score is given based on how far they deviate from a normal baseline. These are then added together to produce an overall score. The higher the score, the more severe the level of clinical deterioration. Research has shown that scores of 5 of higher are linked to increased ICU admission and mortality.

The idea behind EWS is that a deterioration will be flagged up by a score which can then be acted on before the patient deteriorates further. However in practice a patient may go off quickly where their previous score may have been within the normal parameters, be wary when a patient’s overall score may well be zero but when charted you notice that their observations are borderline and if one figure higher would then begin to score. In situations like this it may be prudent to recheck their obs to ensure a correct reading or to increase the frequency of repeating their observations.

It’s also wise not to underestimate the importance of using your clinical judgement in conjunction with good communication with your patient. For instance, don’t dismiss a “feeling of impending doom” reported by your patient, it can have high clinical significance. As before, if you have any concerns about a patient, make sure you escalate them to a member of staff.

The Malnutrition Universal Screening tool (MUST)

MUST is an accredited screening tool from the British Association of Parenteral and Enteral Nutrition (BAPEN), whose aim is to improve management and understanding of malnutrition.

You can use this tool to obtain a score and risk category for the patient and create an action plan. A MUST assessment is generally completed on admission to any inpatient area and for low risk patients is usually repeated weekly. For patients with a higher risk of weight loss and malnutrition this is reassessed more frequently according to level of risk to check the efficacy of any interventions that have been implemented.

To help you complete a MUST assessment, you can find the NHS BMI calculator here and the metric-imperial conversion chart is below.

Waterlow Scale

Developed by Judy Waterlow, a clinical nurse teacher, in the 1980s; the Waterlow scale is used to assess the risk of pressure damage or pressure ulcers forming. These ulcers are formed through pressure, friction or shearing forces; usually on prominent bony surfaces causing damage to the underlying tissue and skin.

Once formed, pressure ulcers can be very problematic to treat and slow to heal so prevention is better than cure! Good manual handling technique to avoid friction and shearing and regular turning for pressure relief and/or use of mattress aids is key to avoiding ulcer formation.

The tool below shows scoring tables for different risk categories to create and overall score. Special risks for consideration are shown in the pink box, such as time spent immobile on an operating table or neurological conditions affecting mobility and therefore patients’ own ability for independent pressure relief.

waterlow score card

To understand more about pressure ulcers you may want to consider a spoke with the Tissue Viability nurses, most wards will also have a tissue viability link nurse who you could speak to.

 

Documentation: key things to consider when writing in patients’ records

Documentation word cloud

When you document in patient notes it’s important you keep things clear and accurate; they should be an honest and timely objective record. Avoid personal language and subjective commentary, the notes should be appropriate and non-discriminatory. Remember it’s a legal and professional document and bear in mind that your patient might read them one day.

It may seem daunting at first and your approach or documentation style may vary between different placement areas but hopefully these tips may help you understand what is expected when you’re asked to document your shift and make sure you check the documentation and records keeping policy at the trust you are based at.

dr handwriting

Ensure you keep your handwriting legible if writing handwritten notes! If you’re typing up electronic records make sure you have spelt everything correctly, beware of any spellcheck programs that may auto-correct any medical terminology they do not recognise.

Electronic records systems will automatically produce a time stamp and will record the name of the person logged in as the author of that note. If you’re handwriting notes you will need to do this by hand and include the date and time for each entry and end with your name, designation and signature. If you need to add anything, add this on a line below and sign next to it. If you need to add or amend any computerised notes, some programs will allow you to log back in and edit the record within a certain time frame of the entry. If not, just simply add a new entry detailing the addition or amendment you want to include.

If you’re editing any paper documentation remember not to use tippex, just use a single line to strike through the text and sign next to it. It’s also good practice to use a line to strike through any blank space on a line at the end of a sentence so nothing can be added in later. You’ll need to make sure your mentor or the registered nurse working with you on that shift also countersigns your documentation.

abbreviations

Although your handover sheet is probably littered with abbreviations like a secret code, it’s best to avoid them when you’re writing up notes unless they are from an approved list. The meaning of some abbreviations may vary between trusts or specialities and may cause confusion if the meaning isn’t clear!

In terms of format and content, it’s really up to you!  Some people prefer to write up the shift chronologically whereas others use an A-E based format or to divide content by body system. For more tips and ideas have a look at Heather’s post here on writing in patient notes.

You may also wish to include any patient contributions to their own care or any significant remarks from them during the shift if relevant. If you do feel that something is significant, for example if a patient has a concern or if you notice a deterioration in their observations or anything else worrying you, make sure you escalate it by reporting things to your mentor or the nurse you are working with first, then you can record it afterwards.

You can find some other resources on documentation here:

 

 

WeNurses takeover!

From Friday 25th May at 7am, I will be curating the WeNurses twitter account for 48 hours!

This is part of a wider project set up by fellow student nurses from other universities. On the last weekend of every month, a student nurse will takeover the well known twitter account! Students healthcare professionals are the future of healthcare, so why not give them a voice? This curation gives student nurses the chance to engage with a huge range of people and professions from all over the world, in 48 hours.

For my curation, I will be focusing on what its like to be a student nurse and the responsibilities required. I’ll also be talking about social media; positives, negatives and of course the use of reflective blogs!

Throughout my curation, I will be following the THINK SOCIAL and NMC Social media guidance.

If you have any questions, please tweet/facebook message/look us up on Instagram/email us on enhancingplacement@gmail.com.