NVQ III

X12

1. Matthew was a 40 year old gentlemen who was attending A and E due to a burn sustained by touching hot sand that had been used to cover up a disposable barbecue on a beach resulting in a blister approximately five centimetres in diameter and required this to be de-roofed by a registered practitioner. This procedure involves to a registered practitioner piercing the blister and allowing the serous fluid to drain away so that the bed of the than can be inspected to ascertained the degree of thickness of the burn.. Mark, a registered nurse who works in A and E, was designated to undertake the task and I acted as an assistant. as well as supporting Matthew throughout procedure. As a HCT, I was required to assist with the procedure as well as providing a supportive role.

• I ensured that the procedure was carried out within the correct manner and in the correct order [X12.2.2]


• Throughout the procedure, I tried to ensure that Matthew was supported appropriately by asking him if he was ok and if different procedures within the overall procedure were acceptable to him [X12.2.5].

1. Firstly, I checked in the Casualty Card that the procedure had been requested. I approached Mark who was designated to perform the task if there were any specific requirements. He told me that apart from the procedure needing to be aseptic, there were no other special requirements [X12.1.7].

1. I washed my hands and dried them thoroughly.

• As part of universal precautions


• To reduce the number of micro-organisms to an acceptable level

1. I approached Matthew and introduced myself, giving my designation and asked to view his name band so I could check this against his Casualty Card.

• To ensure that the correct patient received the correct care


• To ensure that he was aware of whom I was,


• To put him at ease as well as ensuring that he was aware of my designation and the limitations and extent of this. (REFLECTION . I feel very strongly that clients should know this not only for good practice but also for safety. If I had over emphasised my role, then situations could have arisen, with which I was unable to deal, and the client expected me to be able to do so.)[X12.1.2]

1. I explained that the Registered Nurse was ready. I asked Matthew if the doctor who had examined him had explained what was going to happen. I asked if he understood this and if he was happy about this and was happy for the procedure was happy to continue. Matthew replied affirmatively to all questions.

• To ensure that Matthew had had the procedure explained to him and that he understood.


• To ascertain if the client had had the procedure had been fully explained so that a valid consent had been obtained freely and without duress.[X12.1.3]

1. There were no specific requirements for Matthew to be dressed in any particular manner except for having his hand easily accessible. I provided him with a pillow to maximise his comfort. [X12.1.9, X12.1.10]


2. I cleaned to trolley using hot water and hospital detergent. I began to clean at the top of the trolley, working towards me, ensuring that I discarded my cloths after clean each area and that each area was tried afterwards. I ensured that the bottom of each tray and all areas that were not immediately visible were cleaned thoroughly.

• As part of a universal precautions.


• To reduce the number of micro-organisms to acceptable level. [X12.1.7]

1. I asked Mark what equipment was required and placed the following on the bottom rung of the clean trolley.:-

• One sterile dressing pack


• Sterile normal saline pods


• A hypodermic needle


• A sharps bin


• A silicon mesh dressing


• Sterile gauze


• Hypo allergenic tape


• To reduce contamination on the top rung of the trolley


• To ensure that all items were readily available to facilitate smooth running of procedure.[X12.1.1]

1. I took the trolley with Mark to where Matthew was (this was a cubicle in the minor injuries unit of the accident and emergency department). I shut the curtains behind us.

• To maximise client confidentiality and dignity. To reduce airborne contamination as much as possible


• To ensure that all items were readily available to facilitate smooth running of procedure.

1. I asked Matthew if he was comfortable for the procedure to begin. I asked him if he needed to access toilet facilities which he declined.

• To maximise client comfort and facilitate smooth procedure.[X12.1.4, X12.1.8]

1. We both washed and dried our hands and I donned latex gloves and apron were as Mark donned just the apron (as sterile gloves which he would be wearing would be found within the yet unopened dressings pack). We returned to Matthew and I explained that we were both wearing protective clothing so that we could ensure that infection transfer was kept to a minimum as he asked me why we were wearing them. (REFLECTION: It was within my role to answer this question so I was able to do this. If it had not been, I would have deferred to Mark. I think it is very important that I should keep rigidly to actions within my role as this is within the responsibility as a Heath Care Technician. If I were to act outside my role, then this would not only impinge on my own responsibility but also on the accountability of the Registered Practitioner involved).[X12.1.5, X12.1.6, X12.2.1, X12.2.2]


2. I assisted Mark to undo all the necessary pieces of equipment that a required for the procedure. I checked to see that all the sterile packaging was intact and within date. I opened the packaging by peeling at the appropriate edge of the packaging putting the two edges apart and not touching the sterile portion of any of the equipment within.

• To endure at all materials with safe and that sterility was maximised.

1. Mark began to carry out the procedure. He explained that it was going to be painful. He inquired if the client had been offered any medication for this which Matthew said he had been and had declined. Mark asked if he was ready for the procedure to begin. Matthew said that he was ready. When Mark inserted needle, Matthew shouted out. I asked Matthew if he had changed his mind about having the medication. He said that it was going to hurt anyway so it was best to get on with it. (REFLECTION: Matthew here had a choice which he was offered. I thought that it would be good for him to have the medication but he chose not to which was his right. Sometimes, clients are offered choices which are workers think are for the best for them. At the end of the day, it is the client's wishes that have to be followed. Clients must not be rebuked for not taking the advice or the choices that they are given.)


2. Mark covered the wound with the silicon dressing and gauze and taped it to Matthew's hand. I asked Matthew if he was comfortable and cleared away all the unused products back where they could be used for future procedures.


3. I took off my gloves and apron and placed them in a yellow clinical waist bag. I washed and dried my hands thoroughly. [X12.2.1]


4. I washed and dried the trolley as described above so that it was ready for the next use [X12.2.11].


5. I put all the used materials that were disposable in a yellow waste bag which was required procedure for any clinical waste [X12.2.12].


6. . I ensured that there was a sharps bin provided for when Mark needed to dispose of the needle. It is accepted practice that any individual who uses a sharp is responsible for its disposal in a safe manner. Trust policy dictates that all sharps up placed in a sharps bin. As Mark was the one who was using a sharp, it was his responsibility that it should be put to the sharps bin. To facilitate the procedure, I ensured that this was within his easy reach as well as a health and safety measure to minimise the risk of needle stick injury[X12.2.11].


7. When the procedure was finished, I asked Matthew if he was comfortable. He said that he was.


8. I asked him if he had any questions. He asked what thickness of the burn was. This was not within my role to answer this so I referred the matter to Mark who was a registered nurse and this was within his role to answer this question. I asked Matthew if there was anything else I could help him with to which he responded that there was nothing.

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UNIT Z12 - CONTRIBUTE TO THE MANAGEMENT OF CLIENT CONTINENCE

1. Describe the function and appearance of normal body waste: -
(a) Urine.

This is the product of ultrafiltration undertaken by the kidneys. It consists of waist products from the blood such as urea.

It is normally described as being straw coloured and odourless. However, there are many variations of this.

(b) Faeces.

This is the unused remains of food after it has been digested. It contains the insoluble parts of food and fibre.

It is normally formed and mid brown in colour. It must be noted that some individual's waste may differ from what may be considered normal and this not be a problem for that individual.

2. List the observations you would make of the client’s body waste.


Colour?
Smell?
Consistency ?
Was there pain on passing?
Any evidence of blood?
Frequency of micturitions/defections

3. How and where do you record your observations?

Observations need to be recorded in an objective manner that is clear to understand. They need to be made in the client's care plan and any abnormalities need to pass on to the Registered Practitioner in question.

4. Why do we need to know the client’s normal pattern of elimination?


As a benchmark if there are any deviations that may be important.


5. What are the effects of an individual’s personal beliefs and preferences on toileting and cleansing?

One commonly held view is that bowel actions need to be a daily occurrence. This is not so. Some individuals defecate more than once a day and some individual can no have their bowels open for three days. With age, the frequency of bowel actions can be longer. This is a normal process of ageing. Usually, intervention is made after three days or if the problem persists, then regular intervention, such as aperients, can be used to maintain regularity. If an individual believes that bowel actions should be daily, she/he may abuse laxatives to "rectify" this but may cause more harm, such as megacolon, may result.

Some individuals may believe that they need to use disinfectant on the groin/rectal area every time they go to the toilet. This can cause many problems as the skin area can become excoriated and sore due to the corrosive effect of disinfectant and also, the natural flora on the skin can be disturbed or destroyed, increasing the chances of opportunistic infection to set in.


6. Briefly explain the effect that each of the following can have on a client’s elimination pattern.
(a) Diet.
Urine
This may become discoloured by some foods such as beetroot. Also, some food may encourage fluid retention or act as a diuretic.

Bowels
Faeces is highly dependent of diet, as it is the waste products of food that constitute faeces. For example, if an individual has a low fibre diet, then they may have very constipated stools, or, conversely, if a high fibre diet, then well formed stools.

(b) Fluid.
Urine.
Insufficient fluid can cause client's urine to be dark in colour and difficult to pass. Due to the increased acidity due to the increased concentration of the urine, the number of micturitions may be greater and lower volumes of urine may be passed as the bladder is more likely to be irritated by the increased acidity. High fluid volumes tend to result in very pale urine with large amounts passed at each micturition.

Faeces.
Insufficient fluid can cause and exacerbate constipation and excess fluids can cause faeces to be looser.

(c) Medication.
Urine
Diuretics increase micturition volume. Some drugs may cause colour changes

Faeces
Some painkillers can cause constipation. Others may cause loose faeces such as antibiotics as, as well as killing off the required pathogen, can also kill off the helpful bacterial flora in the gut.
(d) Mobility.


7. What may cause the client pain on: -
(a) Micturition?

• Infection
• Trauma
• Kidney stones

(b) Defecation?

• Constipation
• Diarrhoea
• Trauma
• Infection

8. List the legislation/policies that affect the disposal of body waste.

• Heath and Safety at work Act
• Care of substances hazardous to health (COSHH)

9. Describe the correct procedure for: -
(a) Disposing of a client’s body waste and equipment used.

• Where waste has been passed into a bedpan, this should be placed into a bedpan washer (if the bed pan is not disposable) or a masserater (if the bed pan is designed to be disposed of in this way).
• Where incontinence has occurred, all laundry should be sent for washing in a dissolvable red bag then placed in an outer red bag.
• If incontinence has occurred on a hard surface, such as the floor or table. The excess should be disposed of
• Latex glove and disposable aprons should be worn at al times during the procedure

(b) Cleaning up a spillage of urine/faeces.

10. Describe how you would explain the following terminology to clients: -
(a) Micturition.
Passing urine

(b) Defecation.
Having bowels open

(c) MSU.
The taking of a specimen of urine

11. What do you understand the term ‘continence’ to mean?
The ability to fully manage one's toileting. There are varying degrees of continence. An individual can have a catheter and manage it and still be regarded as continent. There are a chain of events that are involved with continence: -
Having the sensation of requiring to use bowels or empty bladder
Being able to access toilet facilities safely
Being able to adjust clothing
The use of toilet facilities without spillage
Being able to clean oneself afterwards
Being able to return to a comfortable position afterwards.

If any link in this chain is broken, then it could be argued that an individual could be said to be incontinent.


1. Briefly explain the effect that hospitalisation may have on a client’s continence.
Describe the actions you take to promote the continence of clients in your care.

Hospitalisation is notorious for causing incontinence. One of the major factors is that of time. Workers tend to have many tasks to undertake and toileting can be low on the list of priorities. Individuals being embarrassed about asking for toilet facilities so they wait until they are desperate to use facilities before asking can exacerbate this. Add this to busy worker who say "in a minute" and the chances of incontience occurring are highly increased.

Time is not only a big factor. Another factor is that of mobility. Individuals tend to not mobilise at their premorbid level. This is due to the fact that they may be ill so mobilisation may be compromised. Also if a client is slow to mobilise, then workers may take short cuts such as inappropriately use continence aids such as commodes, bedpans or incontinence pads which encourage clients to be incontinence.

Some medication can effect continence. Diuretics greatly increase urine output and also the urge to micturate. Antibiotics can kill gut flora and cause diarrhoea.

Continence can be encouraged with pre-thought and giving clients time. A full understanding is also very important. Getting to know one's clients is quintessential to fully promote continence. The promotion of a good client-worker relationship is also good as the client then feels less embarrassed to ask for help with continence.

2. How would you recognise that a client was embarrassed about toileting or incontinence?

Being in hospital can be very frightening for clients. They not only have the fear of what may or is wrong with them but also the fear of if they are incontinent then workers being cross with them for being "dirty". If clients ask for the toilet when they are absolutely desperate. They may also try to hide incontinence by, for example, refusing help with toileting and hiding soiled linen and clothing. Their manner may be abrupt

3. Describe how you maintain confidentiality, privacy and dignity when assisting the client with toileting or incontinence?

• Maximise discretion when dealing with toileting such as not shouting across the room.
• Endeavour to build a constructive trusting professional relationship with clients so that they do not feel intimidated when discussing matters of continence.
• Listen to client as to what works for them and try to involve this when dealing with the constraints that may be incurred by hospitalisation.
• Do not uncover clients unnecessarily during procedures.

4. How do you ensure that communication with the client concerning toileting is not a problem?

• Let them know this verbally.
• Do not use unconstructive verbal and non-verbal cues when dealing with issues of continence
• Ensure that clients have optimum access to the appropriate toileting facilities.
• Ensure they have the bell to hand

5. Identify and explain the 5 different types of urinary incontinence, giving possible causes for each.

Stress

• Bladder weakness, possibly caused by trauma or atrophy can cause urine to leak out on exertion or sneezing

Urge

• If an individual has no real warning before micturition, then micturition can occur before toilet facilities are accessed

Neurological

• If there are impaired neurological pathways between the brain and the bladder, then there may be no message received by the client that they need to go to the toilet

Orientation

• If a client is disorientated or had dementia, then they may not be able to express the desire to micturate or even interpret it as thus. Sometimes, they know that something is wrong but do not know what it is. Also, there may be a problem expressing the fact that they are wet, even if they realise the fact at all

Iatragenic (medically induced)

• Certain medication can cause urinary incontinence. Diuretics can cause vast volumes of urine to be produced over a relatively short time. There is a sudden, strong urge to micturate and toilet facilities may not be able to be accessed at an appropriate speed. Diuretics tend to be given to individuals who are compromised in other ways so the affects of these can compound the problem, especially if the client is not very mobile.

6. Give 3 reasons why ladies are more likely to suffer from incontinence than men do.

• they tend to have shorter urethras
• they have children which causes weakening of the pelvic floor muscles

7. What are the main causes of faecal incontinence?

• constipation
• diarrhoea
• functional
• orientations

8. List the aids and support available for incontinent clients in hospital.

• Incontinence pads
• Incontinence pads
• Stoma bags
• Urostomy bags
• Catheters
• Penile sheaths

9. Why is it important to allow the client choice when selecting incontinence aids and clothing?

• At the end of the day, it is the client's right to choose what product or even lack of product or clothing.
• The client may be the best arbiter of their own needs

10. What exercises and methods of bladder/habit training can be used to promote continence?

• Regular toileting

After a while, the bladder become used to emptying at regular times thus reducing incontinence episodes

• Pelvic floor exercises

Educating clients to perform pelvic floor exercises can help to make bladder control better and thus reduce such things as stress incontinence.

11. Describe the potential effects of incontinence on the client and the impact this may have on different aspects of their life?

Physiological

• Both primary and secondary incontinence can cause a threat to skin integrity as they can cause burning of the dermis. This can cause skin to break and, if the waste products are not removed, then these will get worse
• Although urine is sterile, under normal circumstances, when it leaves the body, as soon as it hits the air, it starts to decompose and airborne bacteria use it for a multiplication medium. Thus it becomes a source of infection. Faeces is already incubation bacteria. Thus, both types of waste pose a possible infection risk.

Psychological

• Some individuals find the concept of incontinence degrading and feel awful about having it as a problem. They can feel dirty.
• Urine is odourless, under normal circumstance, on leaving the body, until it hits the air when the bacteria mentioned earlier can cause it to smell. Faeces smells already. clients can become isolated due to the smell that they have

Social.

Due to the smell and not wanting to be labelled as being incontinent, then some individuals who are incontinent remove themselves from social situations. They tend not to go out as much as they are frightened that they might need a toilet in a hurry, which then can have an affect on their mobility. This can make incontinence worse.

12. Draw a spider chart showing the services and support available in the community for the incontinent client when they are discharged home.

District Nurse ¬® Other Agencies (Pad services, Physiotherapy, Occupational Therapy …..)

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