Prep Notes.

8/17/2019 Prep Notes.

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Possible INTERVIEW QUESTIONS

Please see below further interview questions and answers, please

remember my answers are not conclusive and to try and think of others

yourselves. All answers must have lots of detail when possible. Try to

imagine you are in the situation and explain step by step what you would

do. If you are asked about a question where you have never experienced

the situation then ust say what you would do if this did happen to you.

Lots of detail in your answers is the key to passing the interview.

How to deliver good standard of nursing care

In the !" nurses use what we call the #!$%I#& P$'()%%. *ou can use the

steps of the #!$%I#& P$'()%% for any nursing problem and it is very

important that you make sure in your interview you use these words+

. I -I ASSESS THE NEEDS of the resident/patient

0. I -I PLAN CAE that I give to my patients 1In !" the nurses will

write a care plan listing their actions to take2

3. I -I !"N#T" the care we provide

4. I -I E$AL%ATE the care delivered

&hat will your responsi'ilities as a nurse in the %()

* 5ollow the #6( code of conduct as well as policies of my employer

* I must A%%)%%, PA#, 6'#IT'$ 7 )8A!AT) care provided to my

patients

* I will be accountable for all my actions and make sure that I practise

safe nursing


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* I must P$'T)(T my patients from any kind of A9!%) and

"))P T:)6 %A5)

* I must keep improving my )nglish so that I communicate with fullcon;dence with my patients/ sta


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patients on an individual basis and what may be a good

intervention or one patient may not work for the next.

• Taking time to get to know my patients is therefore essential to a

good working relationship.

#f a patient ,ollapses what would you do)

• Assess the situation, is it safe to approach the patient?

• (all for help

• Assess the patient A9( @ commence (P$ if necessary, follow the

(P$ protocol and get the necessary help.

• If not necessary and patient is still conscious ask how they feel now,

how they felt before it happened and when it happened?

• 6ake patient comfortable until able to decide if it is safe to move

them or do you need a medical assessment

• 6aybe speak with or get the &P on call to assess or emergency

ambulance

• (heck clinical observations 1b/p, pulse, respirations, spo,2 6onitor

as condition dictates

• ocument incident

• (omplete an incident form

• Inform family if patient allows or if an emergency situation

/ou have a patient with non insulin dia'etes and their 0! is

'etween 1 2 3. &hat would you do)

• (heck what the patients normal range is for this time of day

• Ask if they have eaten, or are they about to eat?

• Ask how they feel?

• $eview plan in place for patients diabetes treatment and treat as

per plan.

• If there is no plan in place and the 96 is low for them I will ensure I

give them something to eat 1biscuits, glass of milk or coke2

• $echeck 96 after 0B mins and again if seen necessary

• If it continues to be low/lower consider using glucogel

• (ontact &P if still concerned

• Advise patient to call for nurse should they feel in anyway di


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• 6onitor situation, do they take oral medication for their diabetes,

does it need reviewed

Do,u+ent situation and ensure other sta< members are informed.

Do you understand the ter+ a'use. E4plain to +e what you the

ter+ a'use +eans to you)

• Abuse is any action that intentionally harms or inures another

person. It also encompasses inappropriate use of any substance,

especially those that alter consciousness 1e.g., alcohol, cocaine,

methamphetamines2.

• There are several maor types of abuse+ physical abuse, sexual

abuse, substance abuse, elder abuse, and psychological abuse.

#f you are the nurse in ,harge and a nurse ,alled in si,k- what

would you do)

• Ask the sick nurse to keep us up to date of when she will return

• ook at the sta< roster and try to make changes by asking other

sta< to swap shifts or do extra

• (over any immediate shift myself if I an unable to get cover

• 5ollow the policy in place for emergency cover eg+ phone nursing

agency if possible

• Advise the manager of the situation when they return

How will you +anage a new ad+ission)

•# will admit the patient as per the policy/procedure in place.

• I will assess what needs addressing and prioritise

• I will assess the patients =Activities of daily living= 6aintaining a safe

environment, (ommunication, 9reathing, )ating and drinking,

)limination, -ashing and dressing, (ontrolling temperature,

6obilisation, -orking and playing, )xpressing sexuality, %leeping,

eath and dying and prepare care plans accordingly.

• I will orientate the patient to the new environment and show them

how to call for assistance.

http://en.wikipedia.org/wiki/Human_thermoregulationhttp://en.wikipedia.org/wiki/Human_thermoregulation


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• I will explain the day to day routine and ask about their likes, dislike,

preferences egC do they like to eat in the dining room with others or

alone in their room.• Ask them what they consider to be of most importance to them

whilst staying with us and advise others of these things to try and

make them feel as comfortable as possible.

• This list is endless.......

A resident has a history of ,hroni, heart failure- with a low 'p-

poor oral intake over 53 hours also taking diureti,- what a,tion

would you take)

• I appreciate the resident has heart failure however I would hold the

diuretic until I had the patient assessed by a doctor.

• I would ask the resident to remain on bed rest with their legs raised

to try and increase the b/p

• I would ask why they have not been drinking and treat any problems

in relation to this and advise the importance of drinking

• I would assist with drinking needs

• I would carry out anything ordered by the doctor e.g.C I8 5luids,

monitoring of input and output, regular monitoring of clinical

observations 1bp, pulse, resp ect2

• )nsure the patient is comfortable and has the nurse call bell to

hand.

• Advise patient not to mobilise alone until we get the bp at

satisfactory level, in case they should feel light headed and faint.

• Advise all sta< on shift of the situation

• ocument everything

&hat a,tion would you take if you 6nd a resident on the 7oor

,o+plaining of leg pain)

• &et help

• Assess the situation and approach if safe to do so

• )nsure the patient is as comfortable as possible whilst you assess

them


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• Assess the patient @how did it happen, did the fall, where is the pain,

what type of pain is it, is the pain constant

• (heck the clinical observations @ temp, pulse, bp ect...

• ook at the leg for signs of a break, did they hear a crack

• %peak with the doctor or phone for an ambulance dependent on the

assessment

• 'nly mobilise if certain there is no break otherwise await the doctor

or ambulance and make patient as comfortable as possible

/ou 6nd a resident who is non responsive- what a,tion would you

take)

• call for help

• immediately instigate (P$ protocol @ A9(....

• 8At this point in your interview- 8please e4plain ea,h step of

CP and what you will do and why9

#f you are the nurse on day shift and two residents develop

vo+iting and diarrhoea- what a,tion would you take)

• Immediately instigate the protocol for possible infection prevention

spread eg+ wearing appropriate clothing when entering the rooms,

putting up signs on doors if appropriate, wash clothing and bedding

as per policy for infected linen.

• Inform patient of possible infection status and allow time for

questions and relieve anxieties.

• 'btain samples of faeces for testing 1send for ' and % and (I5 if

seen necessary2 1organism and sensitivity and clostridium di;cile2

1 to send for cdif the sample must be water like and if this is

suspected then alcohol gel must not be used for hand

decontamination and soap and water washing is essential2

• Isolate the patients to their room

• Inform all sta< of possible infection status including domestic sta


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• monitor the patient for signs of dehydration, commence on an input

and output chart

• monitor dietary intake

• administer anti@emetics, anti@diarrhoea medications as the doctor

has prescribe

• imit visitors to the residents and ensure they are aware of hygiene

procedures.

• Inform kitchen sta< and discuss the last 3 hours menu, ???could it

be food poisoning???

• Possibly stop visitors entering home if more residents develop

symptoms

&hat is the reverse 'arrier te,hniue)

Protective Isolation, otherwise known as reverse barrier nursing, is the

separation of a patient who is at high risk from diseases and organisms

that are carried by others. The policy that is put into place helps to

prevent a patient from infection from another patient.

An example of a patient who would require protective isolation is

somebody who has a damaged immune system, which would make them

more susceptible to catching diseases from other patients. The patient

would need to be moved to a single room or ward, which contains a hand

washbasin and a toilet. The door to the isolation room should be kept

closed at all times, and only opened for entrances and exits that were vitalfor the care of the patient. The number of sta< accessing the room would

be kept to a bare minimum so as to limit the risk of further infection.

A member of sta< who is nursing a patient with an infection should not be

treating a patient who is in protective isolation. 5urthermore, any sta


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constantly monitored. All sta< and visitors should be made aware of

the protective isolation and the risks thereof. %ta< members who are

given access to the room should wear rubber gloves and masks for theextra security of the patient. 8isitors are not usually allowed when a

patient is in protective isolation.

E4plain the te,hniue of taking the pulse.

:ow do I check the pulse on my wrist?

• Place your index and middle ;ngers on the inside of your wrist,

below your thumb.

• !se a watch with a second hand and count your pulse for DB

seconds.

• -rite down your pulse rate, the date, time, and which side was used

to take the pulse. Also write down anything you notice about your

pulse, such as that it is weak, strong, or missing beats.

:ow do I check the pulse on my neck?

• Place your index and middle ;ngers on one side of your neck, ust

under your aw, where your neck and aw meet.

•

!se a watch with a second hand and count your pulse for DBseconds.

• -rite down your pulse rate, the date, time, and which side was used

to take the pulse. Also write down anything you notice about your

pulse, such as that it is weak, strong, or missing beats.


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How would you ensure your patient:residents would have a

happy life)

• )ach patient should be assessed on an individual basis about their

likes and dislikes

• )very e


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that impact appetite and creatively formulating a plan that

works for the individual.

• (alories supply the body with energy to conduct normal daily

activities.

• A nutritious diet can signi;cantly improve health and quality of life

in older adults. Along with avoiding tobacco and remaining physical

active, a healthy diet can reduce the risk of developing chronic

conditions such as cardiovascular disease and cancer.

#f you had a patient has pro'le+s with falling a lot- how would

you +anage this) &hat do you think so+e of the ,auses would

'e)

• %peak with the patient and ;nd out why they think it is happening.

• Try to ;nd out the cause and manage it appropriately 1eg+ what

is their diet like, have they got pains,

• Assess patient safety and commence any protocol seen necessary

to prevent further falling

• )nsure nurse call bell is to hand at all times

&hat do you understand the word dignity to +ean)

• Dignity is a term used in moral, ethical, legal, and political

discussions to signify that a being has an innate right to be valued

and receive ethical treatment.

• The $(# believes that every member of the nursing workforce

should prioritise dignity in care, placing it at the heart of everything

we do. *et while dignity is clearly a vital component of care, the $(#

is concerned that it is beginning to be lost.

• -hen dignity is absent from care, people feel devalued, lacking

control and comfort. They may also lack con;dence, be unable to

make decisions for themselves, and feel humiliated, embarrassed

and ashamed.

• Providing dignity in care centres on three integral aspects+ respect,

compassion and sensitivity. In practice, this means+

http://en.wikipedia.org/wiki/Moralityhttp://en.wikipedia.org/wiki/Ethicalhttp://en.wikipedia.org/wiki/Moralityhttp://en.wikipedia.org/wiki/Ethical


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• espe,ting patients= and clients= diversity and cultural needsC their

privacy @ including protecting it as much as possible in large, open@

plan hospital wardsC and the decisions they make• 9eing ,o+passionate when a patient or client and/or their

relatives need emotional support, rather than ust delivering

technical nursing care

• emonstrating sensitivity to patients= and clients= needs, ensuring

their comfort.

• Patients and clients can also experience dignity @ or its absence @ in

what they wear, such as gowns, and in the physical environment

where treatment takes place. 5or example+• facilities such as toilets should be well maintained and cleaned

regularly

• curtains between beds should close properly to o


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The &aterlow s,ore permits patients to be classi;ed according to

their risk of developing a pressure sore.

The categories of risk factors are listed below+

• weight for height

• continence

• skin condition

• mobility

• sex and age

• appetite

• special risks+

o tissue condition and perfusion

o neurological dysfunction

o maor surgery or trauma

o medication

The score in each section is summated to give the overall score which

indicates the relative risk+

• B@G @ low risk

• FB@F3 @ at risk

• F4@FG @ high risk


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• BH @ very high risk

A systematic review found that the -aterlow score o


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The population most likely to experience !TIs is the elderly. )lderly

people are more vulnerable to !TIs for many reasons, not the least of

which is their overall susceptibility to all infections due to the suppressedimmune system that comes with age and certain age@related conditions,

according to the #ational Institutes of :ealth 1#I:2.

*ounger people tend to empty the bladder completely upon urination,

which helps to keep bacteria from accumulating within the bladder. 9ut

elderly men and women experience a weakening of the muscles of the

bladder, which leads to more urine being retained in the bladder, poor

bladder emptying and incontinence, which can lead to !TIs.

Sy+pto+s of %T#s

The typical signs and symptoms of a !TI include+

• !rine that appears cloudy

• 9loody urine

• %trong or foul@smelling urine odor

• 5requent or urgent need to urinate

• Pain or burning with urination

• Pressure in the lower pelvis

• ow@grade fever

• #ight sweats, shaking, or chills

&hat indi,ates the ,olour of the nails of a patient)


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(hanges in the ;ngernails can indicate everything from heart

disease to thyroid problems and malnutrition. :ere are some nail

conditions that might require medical attention.

Nail Separates fro+ Nail 0ed

-hat it looks like+ 5ingernails become loose and can separate from the

nail bed.

Possible causes+

• Inury or infection

• Thyroid disease

• rug reactions

• Psoriasis

• $eactions to nail hardeners

/ellow Nails

-hat it looks like+ *ellow discoloration in the ;ngernails. #ails thicken and

new growth slows. #ails may lack a cuticle and may detach from the nail

bed.

Possible causes+

•

$espiratory conditions, such as chronic bronchitis

• %welling of the hands 1lymphedema2

Spoon Nails

-hat it looks like+ %oft nails that look scooped out. In spoon nails

1koilonychia2, the depression usually is large enough to hold a drop of

liquid.

Possible causes+

http://www.agingcare.com/Articles/Polypharmacy-Dangerous-Drug-Interactions-119947.htmhttp://www.agingcare.com/Articles/Bronchitis-Affecting-the-Elderly-136699.htmhttp://www.agingcare.com/Articles/Polypharmacy-Dangerous-Drug-Interactions-119947.htmhttp://www.agingcare.com/Articles/Bronchitis-Affecting-the-Elderly-136699.htm


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• Iron de;ciency

• Anemia

Nail Clu''ing

-hat it looks like+ The tips of the ;ngers become enlarged and the nails

curve around the ;ngertips.

Possible causes+

• ow oxygen levels in the blood, which could point to heart disease

• InMammatory bowel disease

• (ardiovascular disease

• iver disease

"paue Nails

-hat it looks like+ #ails look mostly opaque but have a dark band at the

tips 1a condition known as Terry=s #ails2

Possible causes+

• 6alnutrition

• (ongestive heart failure

• iabetes

• iver disease

If your senior parent has one of these nail problems, and it doesn=t go

away, make an appointment with your doctor to get it diagnosed.

http://www.agingcare.com/Articles/elderly-heart-failure-and-heart-attack-110500.htmhttp://www.agingcare.com/Articles/An-Overview-of-Diabetes-95735.htmhttp://www.agingcare.com/Articles/elderly-heart-failure-and-heart-attack-110500.htmhttp://www.agingcare.com/Articles/An-Overview-of-Diabetes-95735.htm


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&hi,h are the +ain types of dia'etes and talk a little

a'out ea,h one)

Type = Dia'etes

Type F diabetes is an autoimmune disease. An autoimmune disease

results when the body=s system for ;ghting infection 1the immune system2

turns against a part of the body. In diabetes, the immune system attacks

and destroys the insulin@producing beta cells in the pancreas. The

pancreas then produces little or no insulin. A person who has type F

diabetes must take insulin daily to live.

At present, scientists do not know exactly what causes the body=s immune

system to attack the beta cells, but they believe that autoimmune,

genetic, and environmental factors, possibly viruses, are involved. Type F

diabetes accounts for about 4 to FB percent of diagnosed diabetes in the

!nited %tates.

%ymptoms include+

• Increased thirst

• Increased urination

• (onstant hunger

• -eight loss

• 9lurred vision

• )xtreme fatigue

If not diagnosed and treated with insulin, a person with type F diabetes

can lapse into a life@threatening diabetic coma, also known as diabetic

ketoacidosis.


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Type 5 Dia'etes

The most common form of diabetes is type diabetes. About GB to G4

percent of people with diabetes have type . This form of diabetes is most

often associated with older age, obesity, family history of diabetes, and

physical inactivity,

Type diabetes, formerly called adult@onset or noninsulindependent

diabetes, is the most common form of diabetes. This form of diabetes

usually begins with insulin resistance, a condition in which fat, muscle,

and liver cells do not use insulin properly. At ;rst, the pancreas keeps up

with the added demand by producing more insulin. In time, however, it

loses the ability to secrete enough insulin in response to meals. People

who are overweight and inactive are more likely to develop type

diabetes.

The symptoms of type diabetes develop gradually. Their onset is not as

sudden as in type F diabetes. %ymptoms may include+

• 5atigue

• 5requent urination

• Increased thirst and hunger

• -eight loss

• 9lurred vision

• %low healing of wounds or sores

%ome people have no symptoms.


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Treatment includes taking diabetes medicines, making wise food

choices, exercising regularly, controlling blood pressure and cholesterol,

and taking aspirin dailyNfor some. $ead more on Type iabetes


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• C for Cholesterol. The goal for most people is less than FBB.

The : goal for most people is above 3B. or ObadO cholesterol

can build up and clog your blood vessels. It can cause a heart attackor a stroke. : or OgoodO cholesterol helps remove cholesterol from

your blood vessels.

-hat is a pressure ulcer?

A pressure ulcer is an ulcerated area of skin caused by irritation and

continuous pressure on part of the body. It starts as an area of skin

damage. The damage can then spread to the tissues underlying the skin.In severe cases, there can be permanent damage to muscle or bone

underneath the skin. Pressure ulcers can be very painful and can take a

very long time to heal.

Pressure ulcers can a


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and need to be pulled back up again by someone else 1or you may be

able to pull yourself back up2. :owever, as these sliding and pulling

movements happen, the layers of your skin also slide over each other, aswell as over the underlying tissues. These sliding or =shearing= forces can

also contribute to pressure ulcer formation.

(hanges to the skin as it ages may make this sliding of the skin more

likely. A lot of moisture around the skin 1for example, if you have urinary

or faecal incontinence or you are sweating a lot2 can increase the e


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• Are wearing a prosthesis 1for example, an arti;cial limb2, a body

brace or a plaster cast.

• Are a smoker.

• Are incontinent of urine or faeces 1this causes damp skin which is

more easily damaged2.

• :ave diabetes 1this can a


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• &rade 3 @ this is the most severe form. The ulcer is deep and there is

damage to muscle or bone underneath.

Preventing pressure ulcers

The #ational Institute for :ealth and (linical )xcellence 1#I()2 has

produced guidelines with recommendations for best practice for the

prevention of pressure ulcers. #I() recommends that all people who are

admitted to hospital, a nursing home or similar, or people who are

receiving nursing care at home, should be assessed for their risk of

developing a pressure ulcer. This is usually done by a healthcareprofessional 1usually a nurse2. This assessment should be reviewed

regularly because your situation may change.

There are various pressure ulcer risk assessment scales that may be used,

looking at factors such as your diet, your mobility, your continence, your

consciousness level, any underlying illnesses that you may have, etc.

&hat treat+ents are often needed for pressure ul,ers)

• Pain relief @ a pressure ulcer can be painful. %imple painkillers like

paracetamol may be helpful. %ometimes stronger painkillers are

needed.

• A change to your diet @ a poor diet can slow the healing of a

pressure ulcer.

• ressings @ various di


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=debridement=. %ometimes plastic surgery may be used to

close a pressure ulcer that is not healing. %kin grafts may be

needed.

&hat are the +ain ,hara,teristi,s of a ,are plan)

F Its focus is holistic, and is based on the clinical udgment of the

nurse, using assessment data collected from a nursing framework.

It is based upon identi;able nursing diagnoses 1actual, risk or health

promotion2 @ clinical udgments about individual, family, or

community experiences/responses to actual or potential health

problems/life processes.

0 It focuses on client@speci;c nursing outcomes that are realistic for

the care recipient

3 It includes nursing interventions which are focused on the risk

factors of the identi;ed nursing diagnoses.

A (are plan can address any number of issues that range from extremeaggression, gaining weight, Physiotherapy or stopping smoking, to getting

more communication with other residents/family members

&hat it is essential when it ,o+es to good +edi,ation )

9uild strong trusting relationships as these are fundamental to how wellcare is delivered.

Take time to communicate, update records, and share information.

)nsure regular and formal reviews of care plans and medication.

Prioritise safety by protecting the drugs round, improving systems and

attention to detail.

Identify, capture and develop good practice and help disseminate this to

sta


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6ake use of relevant health professionals to ensure medication

practices are safe.

(larify roles and responsibilities to ensure smoother communication andsafer care.

(onsider medication as part of a holistic approach to care to ensure that

decisions are always made in the interests of the resident and their voice

is heard.

In conclusion, care home sta< need to be aware of the importance of

managing medicines safelyC be con;dent to recognise and deal with

problems as they occurC and be encouraged to report and learn from

previous mistakes

It is also Important to+

• "eep medicines locked away at all times

• -ill have their medicines at the times they need them and in a safe

way

• -herever possible will have information about the medicine being

prescribed made available to them for others acting on their behalf

• :andle medicines safely, securely and appropriately

• )nsure that medicines are prescribed and given by people safely

• 5ollow published guidance about how to use medicines safely

• Any medications administered are recorded immediately and

accurately

&hat key ,on,epts that ,o+'ine to +ake person*,entred ,are a

reality are)

Person@centred care aims to ensure a person is an equal partner in their

health care. The individual and the health system bene;t because the

individual experiences greater satisfaction with their care and the health

systems is more cost@e


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"ey concepts+

• respect and holism

• power and empowerment

• choice and autonomy

• empathy and compassion.

They may be thought of as making di


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'lder people are more at risk they are normally dependent on

someone else.. Abusers may create a feeling of dependency and may also

make the vulnerable person feel isolated, that nobody else cares for themand that they=re on their own.

9roadly speaking, a vulnerable adult is aged F or over, receives or may

need community care services because of a disability, age or illness, and

who is or may be unable to take care of themselves or protect themselves

against signi;cant harm or exploitation.

How will you +ake sure you 6t into the tea+)

I will work hard to earn their respect. I will be friendly and professional to

all. I will also make an eo'- what is your

attitude)

If any of your sta< do anything or refuse to do something T:I% 6)A#% T:)

PATI)#T will su


28/37

• To fully inspect oral cavity, use a Mashlight and a 3 Q 3 gauEe to

facilitate lifting/moving of the tongue

• Inspect top, sides and undersurface of tongue. Assess lips, back of

throat and mucous membranes for any bleeding, odor, discharge or

evidence of skin breakdown or ulceration

• Inspect teeth to observe for breakage, missing teeth, dental carries

or recent trauma. (onsider need for dentistry consult.

• $emove any partial or full plates or dentures.

• Palpate along cheeks, gum line and neck glands for signs of

swelling, enlarged lymph nodes or abscess.

• $eview )TT or #& tube placement and assess for associated

ulcers/early pressuresC discuss with $$T if tube repositioning is

needed

• ocument ;ndings in AI record.

#n ,ase a fa+ily +e+'er ,o+plaints a'out the ,are delivered to

their relative- what would you do)

F. I will take any complain very serious>

. I%T)# T' T:) P$'9)6

0. 5I# -A*% T' %'8) T:) P$'9)6

3. 6A") T:) 6A#A&)$ A-A$) '5 ('6PAI#

4. $)A%%!$) T:) P)$%'# -:' ('6PAI#% T:AT *'! -I '%'6)T:I#&


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D. $)%'8) T:) P$'9)6

K. &' 9A(" and )8)!AT) to see if your plan has worked and if they are

now happy>

Can you na+e the sy+pto+s of appendi,itis)

Appendi,itis typically starts with a pain in the middle of your abdomen

1tummy2 that may come and go.

-ithin hours, the pain travels to your lower right@hand side, where the

appendix is usually located, and becomes constant and severe.

Pressing on this area, coughing or walking, may all make the pain worse.

If you have appendicitis, you may also have other symptoms, including+

• feeling sick 1nausea2

• being sick

• loss of appetite

• diarrhoea

• a high temperature 1fever2 and a Mushed face

How ,an you deter+ine levels of risks)

%everal risk assessment tools or scales are available to help predict the

risk of a pressure ulcer, based primarily on those assessments mentioned

above. These tools consist of several categories, with scores that when

added together determine the total risk score. The 9raden and #orton

%cales for predicting pressure ulcer risk are the most widely used in a

variety of healthcare settings. The clinician uses these tools to help

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determine risk so that interventions can be started promptly.

These tools are only used for assessing adults. 5or those who work with

children, the 9raden R %cale has subcategories that relate to assessingchildren (see “Resources” at the end of this course).

&hat is 0raden S,ale)

The 9raden %cale consists of six categories+

• %ensory perception+ (an the patient respond to pressure@related

discomfort?

• 6oisture+ -hat is the patients degree of exposure to incontinence,

sweat, and drainage?

• Activity+ -hat is the patients degree of physical activity?

• 6obility+ Is the patient able to change and control body position?

• #utrition+ :ow much does the patient eat?

• 5riction/shear+ :ow much sliding/dragging does the patient

undergo?

There are four subcategories in each of the ;rst ;ve categories and three

subcategories in the last category. The scores in each of the subcategoriesare added together to calculate a total score, which ranges from DL0. The

higher the patients score, the lower his or her risk. 15or more information,

see S$esources at the end of this course.2

• ess Than 6ild $isk+ UFG

• 6ild $isk+ F4LF

• 6oderate $isk+ F0LF3


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• :igh $isk+ FBLF

• 8ery :igh $isk+ VG

It is recommended that if other risk factors are presentNsuch as age,

fever, poor protein intake, or diastolic blood pressure less than DB mm :g

Nthe risk level should be advanced to the next level. )ach de;cit that is

found when using the tool should be individually addressed, even if the

total score is above F. The best care occurs when the scale is used in

conunction with nursing udgment. %ome patients will have high scores

and still have risk factors that must be addressed, whereas others with

low scores may be reasonably expected to recover so rapidly that those

factors need not be addressed 19raden, BF2.

&hat is Norton s,ale)

The very ;rst pressure ulcer risk evaluation scale, called the #orton %cale,

was created in FGD and is still in use today in some facilities. It consists

of ;ve categories+

• Physical condition

• 6ental condition

• Activity

• 6obility

• Incontinence

)ach category is rated from F to 3, with a possible total score ranging

from 4 to B.

• ow risk+ UF


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• 6edium $isk+ F3LFK

• :igh $isk+ FBLF0

• 8ery :igh $isk+ WFB

It is important that when the clinician uses a scale, the scale must not be

altered in any way, meaning there cannot be shortcuts or changes to the

de;nitions. Any changes would alter the accuracy and usefulness of the

scale in predicting the risk of developing pressure ulcers.

$isk assessment is more than an act of determining a numerical scoreC it

requires identi;cation of those risk factors that contribute to that score

and minimiEing the de;cits by the appropriateness of the intensity and

e


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o ementiaC however, there is insuXcient evidence to suggest

that enteral tube feeding is bene;cial in patients withadvanced dementia.Y4Z P)& insertion does not improve survival

in end@stage dementia and should be avoided except incircumstances where it can be usti;ed as a palliativeintervention, genuinely in the patients best interest.

o (ystic ;brosis+ P)& feeding is safe, eXcacious and acceptable

in children and adults with nutritional failure due to cystic;brosis but should be carried out only in the context of closeco@operation between cystic ;brosis chest physicians and anenteral feeding team.

o

Peritoneal dialysis+ P)& insertion can improve nutritionalstatus but increases the risk of fungal peritonitis and failure of dialysis. P)& insertion can be undertaken in patients onperitoneal dialysis. ialysis should be stopped for three daysand prophylactic antifungal therapy given.

o 'ro@pharyngeal and oesophageal malignancy+ enteral tube

placement into the stomach may hinder surgical techniques inoesophageal cancer and should be avoided if curativeresection is planned.

P)& tubes may also be indicated in other clinical situations suchas malignant bowel obstruction,YDZ head inury, (rohn=s disease, ;stulae,other causes of short bowel syndrome, AI% and :I8 encephalopathy andsevere burns.

Na+e a few ,ontra*indi,ations to PE


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• Infection+ active systemic infection increases the risk of earlymortality and morbidity post@P)& placement. )levation of serum($P is the most accurate prognostic indicator of poor outcome.

• 'ther comorbidity+ poorer outcome, with increased P)& site and

systemic infection have been reported in patients with diabetesmellitus, chronic obstructive pulmonary disease and low albuminlevels.

• 8entriculo@peritoneal shunts+ placement of P)& tubes increases therisk of shunt infection but this risk decreases with increased timebetween shunt insertion and P)& insertion. Prophylactic antibioticsmay further reduce the infection risk.

• Anatomical considerations+ in patients with severe kyphoscoliosis,the stomach is often intrathoracic. This particularly applies topatients with cerebral palsy. $adiological and endoscopicapproaches may be impossible. A combined laparoscopic andendoscopic approach can be tried but this requires a generalanaesthetic, which also represents a considerable risk for thepatient.

P)& insertion method

• In the maority of patients in whom there is an indication forpercutaneous enteral tube feeding, an endoscopic gastrostomy isthe procedure of choice.

• The treating doctor has a duty to obtain informed consent from

competent patients and to undertake adequate consultation withthose closest to patients not competent to make the decision.

• P)& tube placement should be carried out under full aseptictechnique.

• Antibiotic prophylaxis is indicated to prevent skin site infection.

• In areas of high meticillin@resistant Staphylococcus aureus 16$%A2prevalence, oro@pharyngeal colonisation should be identi;ed andmanaged prior to P)& tube placement.

9ene;ts of P)& feeding

http://www.patient.co.uk/doctor/consent-to-treatment-mental-capacity-and-mental-health-legislationhttp://www.patient.co.uk/doctor/consent-to-treatment-mental-capacity-and-mental-health-legislation


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9ene;ts include+

• It is well tolerated 1better than nasogastric tubes2.

• #utritional status is improved.

• )ase of usage over other methods 1nasogastric or oral feeding2reported by carers.

• %atisfactory use by home carers.YGZ

• ow incidence of complications.

• $eduction in aspiration pneumonia associated with swallowing

disorders.

• (ost@e


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• #ote the measuring guide number at the end of the external ;xationdevice.

• $emove the tube from the ;xation device and ease away from theabdomen.

• (lean the stoma site with sterile saline.

• ry the area with gauEe.

• $otate the gastrostomy tube to prevent adherence to sides of thetrack.

• $e@attach the external ;xation device to the abdomen.

• Attach the gastrostomy tube gently to the ;xation device andposition as before according to the mark/number on the tube.

• Avoid use of bulky dressings.

(omplications

#++ediate 8within @5 hours9+

• )ndoscopy@related+

o :aemorrhage or perforation.

o Aspiration.

o 'versedation.

• Procedure@related+

o Ileus.

o Pneumoperitoneum.

o -ound infection.

o -ound bleeding.

o Inury to the liver, bowel, or spleen.


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Prep Notes.

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