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A Review of a Service Users Experience in a Community Hospital

This essay is a review of a service user’s experience in a community hospital following discharge from an acute hospital. During this essay the patient will be referred to as Mrs C in accordance with the Nursing and Midwifery Council Code of Conduct, this is to maintain their privacy and confidentiality (NMC 2018). Consent was gained from the student nurses’ patient each time a task was to be completed. It is important to gain consent from patients, as the patient has a right to either accept or decline treatment. Gaining consent is defined as the patient giving permission or agreeing for healthcare professionals to carry out a task, assessment or examination. Also ensuring that patients have understood the information given to them (Kelly 2017). The student nurse followed the #hellomynameis campaign when introducing herself to her patients. The #hellomynameis was introduced following the post-operative admission of Dr Kate Granger in 2013 (Granger 2013).

The eighty-four-year-old female was discharged to a community hospital, following an admission for a Urinary Tract Infection (UTI). She was admitted here for rehabilitation. Mrs C had comorbidities consisting of Hypertension, Asthma, Sarcoidosis and Coeliac Disease. Comorbidity or multimorbidity is a medical term used to describe a patient that has one or more illnesses or diseases at one time (McGeorge 2012). During her admission, she underwent 1:1 care from Occupational Therapists and Physiotherapists to encourage her confidence and get her back to baseline mobility.

On admission following her assessment, it was documented in her care plan that she had a grade two pressure ulcer on her natal cleft (NMC 2018). National Institute for Care and Excellence defines a pressure ulcer as damage to a localised area of skin from repeated pressure, shearing or friction (NICE 2005). The three care aspects chosen for this assignment are measuring and recording height, weight and BMI, Infection control/standard precautions and Aseptic Non-Touch Technique (ANTT). These aspects were chosen due to them linking in with the care that was provided to Mrs C.

There are many ways to prevent infections, one of which is hand hygiene. This is an effective way of infection control and prevention, to reduce the risk of cross-contamination and the spread of healthcare-associated infections (HCAi). Hand washing helps to remove bacteria from the hands to prevent the transmission of germs to patients and other staff members, but also the student nurse (WHO 2019). According to The World Health Organisation (2019), more than one million cases of HCAi’s are recorded at any given time, although it is thought to be more. This is due to health care professionals either not washing their hands, or not washing them correctly. Hand washing is not only the one thing that can protect the patients and the clinical staff.  Infection control and standards precautions do not just consist of good hand hygiene, personal protective equipment (PPE) is available to use dependant on the procedure that is being carried out. PPE that is provided in any clinical area are aprons, gloves (sterile and no sterile), sterile gowns, eye protection and masks (Dougherty et al 2015: p48).

Health care professionals follow the standard precaution guidelines set out by the National Institute for Health and Care Excellence (NICE 2014). The student and registered nurses adhere to the following procedure whilst washing their hands. Procedure guidelines consist of twelve steps to ensuring the nurses’ hands have been decontaminated correctly.

Firstly, remove any jewellery, rings, watches, bracelets and roll up sleeves. This is to abide by the ‘Bare Below the Elbows’ policy, which was first introduced in 2008 by the secretary of state for health Alan Johnson. This was recognised throughout the National Health Service (Briggs 2013). Secondly, cover any cuts or grazes on with waterproof dressings, nails should be short and clean, with no nail varnish or false nails. Turning the taps on and ensuring that the water is flowing away from the plug hole and the rate of flow prevents splashing. Plug holes can be contaminated with microorganisms and splashing water can transfer them onto the person washing their hands. The water should be hand hot, this is hot enough that it does not scold the skin. However, a study that took place at a university in America in 2016 suggests that using cold water is just as effective as hot water. It also found that washing hands for slightly longer was more effective at ridding bacteria (Jenson et al 2017).  Wetting the surfaces of the student nurses’ hands and wrists, apply one to two drops of liquid soap to palms then rub hands together for a minimum of ten to fifteen seconds. Ensuring that when rubbing hands together to spread the soap that the student nurse pays particular attention to areas that are usually missed. These are the thumbs, fingertips and between the fingers. Once finished rinse hands thoroughly under the running water, making sure that there is no residue left, as this can cause damage and irritation to the skin (PRATT et al 2001). Following this turn off the taps using elbows or wrists ensuring that the nurses’ clean hands are not used as this can contaminate them again. Lastly, dry hands thoroughly with single-use paper towels and dispose of them in the correct receptacle. When disposing of paper towels, use the foot pedal on the waste bin to avoid touching the lid and contaminating clean hands (Dougherty et al 2015).

After the student and registered nurse completed the hand hygiene routine, the registered and student nurse introduced themselves to Mrs C, then welcomed her to the ward. During her admission, it was explained that admission documents needed to be completed, so that the right care was provided for her. Consent was gained from Mrs C to record information she told the registered and student nurse. Documents should be completed within the first two hours of the patient being admitted (NMC 2018). These documents are recorded on the NHS’s SystmOne platform. This platform is widely used across the UK, with many healthcare establishments being able to access patient information, granted that they have given consent for information to be shared (TPP, 2019). Some documents are written in booklets and placed at the end of the patient’s bed. These will then be filed in the patient’s medical notes once discharged (NMC 2018). As mentioned above documentation is adhered to throughout, part of the admission process is to record the patient’s height, weight and Body Mass Index (BMI). This is due to keeping accurate and up to date records. This can be for weight loss/gain monitoring and administration of weight reliant medications (RCNi 2016). Foremost, it is an assessment for the registered and student nurse to identify if the patient is underweight, overweight or malnourished. This is in association with the Malnutrition Universal Screening Tool (MUST) which was introduced in 2003 following a report issued that over three million people are at risk of being malnourished whilst in hospital. It is an undertreated and under-recognised illness in the United Kingdom (Elia and Russell, 2008). Malnourishment leaves patients being prone to longer admissions, illnesses and a greater risk of attaining a pressure ulcer. (Bapen.org.uk 2003).

Consent was gained from the patient while the student nurse explained to her why she needed to be weighed. This was completed using the wards seated weighing scales. The student nurse checked and confirmed that the weighing scales were in good working order and that the manufacturing guidelines are followed. The scales were cleaned using green clinell wipes. Universal Clinell wipes are single-use, to prevent cross-contamination (GAMA healthcare 2019). Nurses’ hands should be washed between patients and tasks to prevent the spread of infections (CDC 2017). Turning on the scales and checking to make sure that they have been calibrated, the weighing scales were then taken to the patient’s bedside. The student ensured the scales were on a hard-flat surface and free from clutter. This is to obtain the most accurate reading and risk assessing the area for danger, to prevent in-hospital falls. The scales were set to zero and she was assisted to sit on the scales using her zimmer frame and the assistance of one person. Once the patient was sitting still and the weight on the scales had settled, it was recorded then entered into SystmOne. Next, the patient’s height was measured using a Marsden Leicester Height Measure. The Stadimeter is an accurate way to measure a patient’s height (Durkin 2014). If it is not possible or appropriate for the patient to stand, the MUST screening tool has an alternative for measuring a patient’s height. This is by measuring the patient’s ulna length, if achievable the left side. A single-use or a tape measure that can be cleaned is used to measure the distance from the patient’s point of elbow to the prominent bone of the wrist. In the must tool booklet, there is a table that will help to define the patient’s height (Bapen.org.uk 2003). In this instance, this method was not required as the patient was able to stand for a short period.

Once the stadimeter had been assembled correctly and all the parts were present, the student and registered nurse both disinfected their hands again using alcohol gel. The patient was instructed to remove her shoes and step on to the stadimeter. After an assessment, both the student and nurse were confident that the patient could do this with minimal assistance. The patient was asked to face forward and to stand as tall as possible. Posture was maintained by the student nurse demonstrating to the patient how to balance, by placing their feet flat on the ground and slightly apart. The patient’s arms were left to hang loosely by her sides. If necessary, the registered or student nurse may assist the patient to align their head in the right position. However, in this patient’s case, she was more than capable of doing this independently. Once the student was happy with the patient’s position, the measuring plate was pulled down to the top of the patient’s head. The box on the side of the measuring device indicated the accurate height by following the arrows. Once finished, the patient was assisted off the stadimeter. All equipment was then cleaned after patient use with clinell universal wipes (GAMA Healthcare, 2019). The student nurse then documented the results along with the patient’s weight on the SSKIN Care Bundle, in association with the MUST screening tool. SSKIN is a care bundle that was introduced in the UK in 2004. The bundle was used as an initiative in the UK to try and stop preventable pressure ulcers (Mccoulough 2018). Once care plans had been tailored to Mrs C’s needs, it was identified to promote independence and for her skin to be checked regularly. Furthermore, she was advised to sit on a pressure cushion and have a pressure-relieving mattress. Pressure-relieving devices help to alleviate pressure discomfort and prevent pressure damage in patients. These can be via specially manufactured cushions that evenly distribute pressure. Pressure-relieving mattresses, work in the same way as the cushions. However, there are different types of mattresses. Static foam mattresses are similar to the cushions, the other type is an air pressure mattress. This type of mattress has individual cells that inflate and deflate to adjust the pressure from the patient (Sidhil 2019). On this occasion Mrs C did not require this type of mattress.

As mentioned above Mrs C has a grade 2 pressure ulcer with a dressing insitu. This is to aid healing and provide added protection to the area and surrounding areas due to Mrs C being underweight. The student nurse used the Aseptic Non-Touch Technique (ANTT) when changing the dressing for Mrs C. Using this technique correctly entails wearing gloves (sterile and non-sterile) and an apron at all times, this is the standard PPE provided to ensure that the nurses’ uniform has a level of protection from being contaminated with microorganisms (Dougherty et al 2015: p68). As discussed above Mrs C was informed of the procedure that was taking place and consent was gained. The student nurse then washed her hands and collected all equipment that was needed for the dressing change and took it to the patients’ bed side on a dressing trolley. Closing the curtains around the patient’s bedside to maintain privacy and dignity (Lawson and Peate, 2009). The student nurse takes a clinell universal wipe to clean the dressing trolley, the top, bottom and legs were wiped with single strokes so to not cross-contaminate the area just cleaned. The equipment required for the procedure is placed on the bottom of the trolley, so that is does not come into contact with the top of the clean trolley. Putting on non-sterile gloves and disposable apron, the dressing was carefully removed from the patient, this enables the student nurse to fully observe and assess the wound, the dressing and gloves are then disposed of in the orange clinical waste bin (Dougherty et al 2015: p79) Next the student nurse cleans her hands again with alcohol gel and takes the dressing pack, checks that it is intact and in date. Opening the packaging, she slides the contents on to the top of the trolley without touching it. The dressing pack is folded in a way that it can be easily opened out with contaminating the contents, opening the corners of the pack, the student nurse now has a sterile field. The student nurse then takes the rest of her equipment and opens them without touching the inside and tips them onto her sterile field. Hands gelled again and a new apron applied, liquids were emptied into the gallipots and the sterile glove package opened onto a clean surface, the student takes the cuff of the first glove and slides her fingertips inside, being cautious not to touch the outside, pulling the cuff down she spread her fingers to help the application of the glove. Next inserting her sterile glove inside the cuff of the opposite glove, she slides her fingertips inside and repeats the process. Now the student is sterile, she can begin her wound cleansing. During the procedure being completed it is important for the student to talk and listen to her patient, this gives the student nurse a good opportunity to create a healthy relationship (Sheldon, 2009)

. Using one hand as a dirty hand and the other clean, it is important to keep these separate as to not contaminate each hand, taking her clean hand. She uses wet gauze and passes it to her dirty hand, cleaning the wound with one stroke then dispose. Repeat this process as required. Once the area has been cleaned, the recommended dressing was an allvyen gentle border. This is due to it having multi layers that consist of a hydrocellular foam, waterproof breathable outer layer, silicone adhesive layer, these help to protect the wound and aid healing, as well as the intended purpose of preventing any more damage the dressing is designed so that it does not have to be changed to often (smith-nephew, 2019). Once complete the student removed her gloves and apron, wraps the dressing pack and disposes of them in a clinical waste bag. She they assisted Mrs C to get dressed and ensured she was comfortable (Dougherty et al 2015). For the importance of record keeping and accurate information, the above was documented in Mrs C’s patient care plan under SSKIN. Photos had been taken with the permission of Mrs C to keep a record of the wounds progress (NMC 2019).

In conclusion the care received by Mrs C from the student and registered nurses was in her best interest and in compliance with evidence-based practice. It is important for the student nurse to deliver evidence-based practice to her patients, as the care industry is ever changing, with on-going research studies and trials they discover new and improved ways of delivering safe and efficient care (Ellis 2019). This assignment has shown that the care aspects spoke about have a rationale behind them ensuring that the patient is always first at hand. Nurses whether qualified or student have a duty of care to provide the upmost professional care but ensuring that their practice and knowledge is up to date. We base our clinical decisions on past experience and evidence-based knowledge gained from our mentors which can be backed up by our own research. (NMC 2018)

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