Urgent And Unscheduled Care Nursing Essay

Scenario 1: Tom is a 45 year old car mechanic who has sustained a laceration across the palm of his right hand on a piece of machinery whilst at work. The wound has been covered with a sterile dressing but is still bleeding as he arrives with a work mate who has driven him to the nearby Accident and Emergency department. As you greet him, Tom tells you he is HIV positive and takes antiretroviral medication regularly, and that he is very well at the moment

Using the above scenario this paper will critically explore the nursing decision making process in the urgent and unscheduled care setting, with consideration given to the relevant theories and current policies surrounding this process. Consideration will be given to the risk assessments required to actively manage treatment whilst evaluating the contribuation of the Multi-disciplinary team in the process: Urgent And Unscheduled Care Nursing Essay.

Urgent and unscheduled care can be defined as any unplanned contact within the NHS by a person seeking care or advice which may be delivered by a number of providers in various settings with an expectation of 24/7 availability (DoH 2006). On an average day in the National Health Service (NHS) 34,700 people attend an accident and emergency (A&E) department, 11,700 need urgent transport to hospital by ambulance and over one million people contact their general practitioner (GP). (DoH 2001). The NHS Plan (2000) was the Government’s plan for reform and investment in the NHS and one aspect of this plan was that everyone attending accident and emergency departments would be seen within 4 hours with the assumption that this would lead to better clinical outcomes (DoH 2000) and whilst there have been no clinical measure to support this assumption what has become apparent is that emergency admissions have increased by 66% over the last ten years for the over 75’s (Clay & Longman, 2010. These figures highlights the need to address the problems associated with increased use of unscheduled care services by reforming the services available and providing services that are responsive to people and more efficient in the deployment of resources (DOH 2010).

The implications of providing 24/7 urgent and unscheduled care in the NHS are far-reaching with huge financial implications in terms of provision of staff, access to out of hours medications, clinical decision makers….

With the encouragement of central government intitaive the last ten years has seen a rise in PCT’s setting up centres to broaden access to urgent care services and whilst this has produced some good results in terms of access it can be seen that often these services are working against each other in redirecting activity to another part of the system resulting in a morea fragmented service that is difficult for patients to understand or navigate (Carson, et al, 2011). In an attempt to manage this confusion around access identified in the Deparment of Health’s Our NHS, Our Future (2007) the government have introduced a new NHS help line, NHS 111, currently being piloted in parts of the country with a view to it being rolled out nationally in 2013 supersedeing the current NHS Direct service, offering free service providing advise 24/7, 365 days a year (Harmoni, 2012). Initial assessment is carried out at the first point of contact by fully trained NHS 111 call advisers, supported by experienced nurses. Urgent And Unscheduled Care Nursing Essay. Using NHS Pathways to assess callers needs safely and effectively patients are then directed to the appropriate NHS service such as rapid response teams, community matrons, minor injuries units, and out of hours services (Harmoni, 2012). The aim is to improve and simplify access to non-emergency healthcare for patients by providing access to a full range of services including referrals into community, primary and secondary care services. The service aims to both enable the best outcome for the patient as well as deliver an improved patient experience (DoH, 2010). However, critics of the service have suggested that the lack of clinical training of the call handlers will result in mis-direction and consequently delays in treatment for patients with additional burden of costs for already financially stretched NHS (RCN, 2012), a point supported by a recent independent report on the service which suggests an increase in A&E attendances in some piloted areas (Calkin, 2012). With regards to the above scenario the use of NHS 111 for Tom may have been appropriate and direction to a minor injuries unit may have been advised.

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The decision making process begins with the identification of a problem and ends with the evaluation of choices and taking a course of action (Bernhard & Walsh, 1990) with nurses actively using decision making in various situations from planning patient care to prioritising their work load (Finklemann, 2006). The process of decision making is a dynamic one carried out in a complex and changing environment, having an awareness of approaches to decision making will enable the nurse to develop her skills of crititical thinking and subsequently make more effective decisions (Marquis & Houston, 2009). Aloi (2006 ) suggests that many experienced nurses use intuition in decision making, that is relying on their gut-level feelings to take appropriate action however some argue that intuition should only be used as a complement to more empirical decision-making models (Ward, 2009) arguing that relying soley on intuition may result in mis-judgement. Urgent And Unscheduled Care Nursing Essay. This model requires a level of experience in order to subconsciously recognise similarities with previous experiences (Benner, 1984) and is inextricably linked with expertise (Manchester Triage Group, 2006), and for this reason would not be a suitable model for a newly qualified nurse in the case of Tom presenting in A&E, however intuition may form part of a strategy in the overall decision making process (Manchester Triage Group, 2006).

The information-processing model is a psychological theory much used in research in medical decision making and characterized by a scientific approach to making decisions (Joseph & Patel, 1990). . Hamers et al. described four major stages of this process in nursing as, gathering preliminary clinical information about the patient, generating tentative hypotheses about the patients’ condition, interpreting the initially registered cues in light of the tentative hypotheses, and weighing the decision alternatives before choosing the one that fits best in light of the evidence collected. Earlier knowledge acquired about the situation at hand is included in this process. Critics of this theory argue that it requires problems that have some basis of understanding in your own experience and argue that often problems faced by nurses are complex and ill-defined making the this process difficult to apply (Crumbie, 2000).

Decision making is an essential and integral part of nursing practice and requires both thought and intuition based on professional knowledge and skill with an expectation of being able to gather, interpret, distriminate and evaluate data. These decisions require a framework of reference in order to make sound decisions that are safe and patient focused (Purcell, 2003). Triage is a nursing function developed in the 1990 ’s that has been adopted nationally in Accident and Emergency departments to deliver an auditable method of assigning clinical priority (Walsh & Kent, 2001). Urgent And Unscheduled Care Nursing Essay.

Utilising the information-processing model and integrating with a triage system of assessment with regards to Tom could appropriately applied the decision making process for a graduate nurse. Manias et al., (2004) in their review of decision-making models used by newly qualified nurses found this was the prevalent model used and was observed in 25 out of the 37 client interaction. The triage approach to decision making follows five steps; identifying the problem and selecting the relevant flow diagram, the second step utilises the flow diagram and pattern recognition and suggests structured questions to aid rapid assessment. Once the data has been collected it can be analyised by drawing on knowledge of previous experience and using the flow diagrams to link the decision making process into the clinical setting. From the 5 possible triage categories the appropriate one is selected, with ongoing monitoring and evaluation.

On presentation to A&E Tom would be seen by a Nurse Practioner, ( a qualified nurse with the competencies to autonomously assess, treat and discharge patients without referring to any other clinician (NHS, 2011)) , where preliminary clinical information would be gathered to identify the problem and baseline observations made and accurately recorded with any anomalies reported to a senior staff member. Providing that no life-threatening problem has been identified the main goal of intervention would be pain-relief and stopping the bleeding (Walsh & Kent, 2001). An assessment of pain would be made using a pain ladder scale(REF)and if necessary analgesia would be prescribed. Any relevant past medical history including any allergies would be noted as well as any current medication being taken. The wound assessment and evaluation is critically important all information will determine the overall management of the wound (Toulson, 2001). It would be appropriate to ascertain how the accident occurred, the time elapsed since occurrence, was the wound caused by machinery and if so ascertaining current tetanus status would appropriate. Referring to the management guidlines for tetanus-prone wounds (DoH, 2006) a decision would be made as to the requirement for passive or active immunisation (Toulson, 2001). Wearing appropriate PPE as standard universal precautions which states that all patients should be assumed to be infection risk (Wilson, 2006), the wound would be assessed for size, obvious sign of foreign body , possible underlying structural damage and if deemed necessary a referral to xray would be made. Urgent And Unscheduled Care Nursing Essay. From this initial assessment utilising the wound flow chart (Manchester Triage Group, 2006) would prioritise Tom’s care between urgent and standard depending on the ability to stop the bleeding. Due to Tom’s positive HIV status, and therefore possible immunocompromised status, and the potential for the wound to be dirty he would be considered at higher risk for possible infection (Meyers, 2011) and for this reason would need to be referred to a nurse prescriber or doctor for prophylaxis antibiotic treatment. Treatment for Tom would consist of closure of wound with sutures and ascepticly applying a wound dressing. Information would need to be given to Tom for care of the wound and a referral made to the District Nurse Team at his GP practice for removal of the sutures. Following the Nursing and Midwifery Council guidelines consent would be sought before undertaking any treatment and Tom’s rights to to accept or decline treatment would be upheld (NMC 2008).

Collaboration is key to meeting the core objective of unscheduled care which to ensure that patients are able to to access the right help and receive prompt and rigorous assessment followed by the right care, in the right place and the right time (NHS, 2011). A multi-disciplinary approach to urgent care offers a continuity of treatment supported by appropriate referral pathways to meet the whole needs of the patient with the possible reduction of service duplication and faster assessment process leading to effective and timely treatment.

On his journey through the A&E department Tom can expect to come into contact with various practioners who will be providing a holistic approach to his care. The Triage system could be effectively and safely implemented by a relatively junior nurse following the algorithm to deliver an acceptable level of assessment, however without additional experience and expertise the assessment would be closely tied to the physiological findings with little consideration of other factors (Walsh & Kent, 2001). The Nurse Practioner (NP) is an autonomous nursing role that implies the ability to consult with and prescribe care for patients without referral to a doctor providing a more individually tailored package of care whilst being accountable practioners able to justify their actions at all times (Walsh, 2000). The employment of the NP benefits the patient by providing continuity of care and subsequently a more expedient delivery of care (Pines & Everett, 2007). In the case of Tom the NP would be able to make a clinical decision regarding his treatment, assessing the need for xray or referral to a orthopaedic specialist for further assessment. The ability to interpret xrays would be fundamental to this NP role, enabling the NP to proceed with treatment based upon these findings. If the NP has independent prescribing status then it would possible for medications to be prescribed for Tom from either a limited or extended formularly (Hatchett, 2003), without this status Tom would need to be seen by a doctor or prescribing pharmacist. Urgent And Unscheduled Care Nursing Essay.

Emergency care is a speciality in the medical field concerned with providing health services to unscheduled patients with injuries and illnesses that require immediate medical attention. They offer the first step of treatment to initiate stabilization to individuals with life-threatening injuries which call for a lot of skills and specialization. The emergency care unit plays a massive role in determining the well being of a patient received under critical conditions.  Triage is the process used to determine the urgency and severity of patients’ conditions to help decide the order of treatment of a large population of patients. It is usually applied when the number of patients is high compared to the healthcare services available which cannot attend to all of them at the same time.

Role of Triage in Emergency Care

Triage is very important in emergency health care since it enables medical practitioners to know the severity and danger of the injury on the patient. It is performed by a triage nurse whose primary role is to make the first assessment on patient brought to the emergency room. The job demands for quick decision making since the patient must be fixed in the order of treatment as fast as possible. Role of Triage in Emergency Care A fast evaluation of a patient’s condition in the hectic and chaotic environment of the emergency room demands a lot of experience and knowledge. Time management is one of the significant factors considered when working as a triage nurse.  Any wrong decision during this step of health care delivery affects the safety of the patient and may cause permanent damage and even death.

Duties performed by triage nurses in emergency care also include cleaning injuries, taking blood samples, provision of stabilization medication to patients and moving patients where they need to be for better care. Triage nurses put patients in different categories for health care services attention depending on where the injury has been sustained and their ability to stop further damage. An injury that they cannot do anything to prevent it from worsening is categorized high priority and is attended to first. Urgent And Unscheduled Care Nursing Essay. Those injuries that can be worked on are put in the lower category because they present no danger to the patient. Medical resources are also used sparingly since it aids in the proper planning of the treatment process for it to be efficient.

The role of an emergency room nurse can be demanding and may require a nurse to use many different nursing skills at certain times to take care of a variety of patients. The main role is the nurse must be skilled in client assessment, priority setting, critical thinking, multitasking, and communication. The nurse must be knowledgeable and able to make some decisions independently. The nurse also needs to be able to prioritize so the pts who are at highest risk of major injury or complications are treated first. Urgent And Unscheduled Care Nursing Essay.

In a busy ER, time management is important too because there may be a lot of pts waiting for care. The nurse must be mentally prepared for rapid change and be able to keep calm in hectic situations. The ER nurse must be able work well in a team and be able to interact with all levels of ER professionals in order to give the pt the best possible care. ER nurses also need to be flexible and adapt quickly to rapidly changing situations.

Nurses usually choose to work in the emergency area because they dislike routines and thrive in challenging, stimulating work environments. In one situation I observed, a male came in with chest pain. The nurse went to get him from the waiting area right away and hooked him up with the heart monitor and got him ready for an EKG. The nurse stayed calm, and gathered the information from the pt next. She had her own system for what she normally does depending on the level of the pt’s injury. Another key role is teaching. The ER nurse needs to make sure the pt knows what to do after discharge and/or when they may need to return to the ER for further testing or treatment. There are some similarities and differences in the roles and responsibilities between emergency care nurses and other general staff nurses.

The scope of practice for ER nurses includes managing pts across the lifespan; from birth to death. Other general nurses usually pick their area of work, so they mainly work with pts who have certain conditions, mostly all adults, or mostly children. Usually prior to employment in the ER most nurses are required by employers to have 6 months to one year in an acute care medical surgical or critical care unit before working in the ED. Urgent And Unscheduled Care Nursing Essay. This is so they have developed some of the skills and competencies in basic nursing care and organizational skills before entering the ED, while the general nurse can start out on a medical surgical floor with no previous experience (other than school and their license to practice). The ER nurse is also required to have two general types of certification: the Health Care Provider Basic Cardiac Life Support and Advanced Cardiac Life Support. Some facilities even require Pediatric Advanced Life Support and the Certified Emergency Nurse certification. The general nurse does not need to have any special certifications. The ER nurse also has a higher risk for errors and adverse events because of the chaotic nature of emergency management and key health risks are not as evident. For example if a pt comes in unconscious, and the pt’s name, health history, and allergies aren’t known there is a higher potential for error. The general nurse usually has an updated H & P with allergies sent to the floor right along with the pt who is wearing a name band already. Similarly, the ER nurse and the general nurse all need to have competence in basic nursing skills, time management, prioritization, knowledge, and critical thinking.

They must both have knowledge to be able to work independently. Depending on the place of employment most facilities require all medical personnel to have an updated CPR card, so ER and general nurses have this in common also. Another similarity is communication. Both nurses still need to be able to communicate well with other medical personnel and pt’s families. In the emergency care area the nursing process is a little different, but parts are still used, although with the rapidly changing environment, the process is sometimes a little out of order. First, the ER nurse assesses the pt usually by asking questions about health history, allergies, and reason for coming to the ER. Next, the emergency nurse must still do a head to toe assessment, depending on the signs and symptoms exhibited by the pt.Urgent And Unscheduled Care Nursing Essay.  Another ER assessment done in trauma pts is the use of the “primary survey,” which organizes the approach to the pt so that immediate threats to life are rapidly identified and effectively managed. The primary survey is based on the mnemonic “ABC” and “DE” for major trauma.

This is the order of priority. The A=airway/cervical spine, B=breathing, C=circulation, D=disability, and E=exposure. Sometimes nursing diagnoses are noted if the pt is at high risk of injury. Next the doctor assesses the pt, so no nursing diagnosis are planned or implemented at this time. The doctor then makes the decision is the pt needs to be admitted to the hospital or if the pt will be discharged home with instructions for continued care or follow ups. If the pt is admitted, the nurses will start to put together nursing diagnosis which will be planned, implemented, and evaluated when the pt moves a room in the hospital.

In the ER pt care is coordinated by use of team work. One nurse will start to assess the pt. The receptionist will get a wristband printed up. The ER nurse will report to the ER doctor prior to the pt being seen by the doctor. The nurse also collaborates with x-ray and ultrasound technicians, respiratory therapists, lab technicians, and social workers. The interaction between all the medical personnel helps assure the pt receives the care and testing needed. Autonomy, or independence is a key trait the ER nurse must display. Due to the high volume of pts, various levels of injury, different disease processes, and complications a nurse needs to be well educated on what to do in these situations, so she can independently report to the physician or start up emergency facility protocol without a huge amount of help or questions for the physician. In order to work independently the nurse must be skilled in pt assessment, priority setting, critical thinking, multitasking, flexibility, and adaptability. The nurse also needs to have a good knowledge base. The ER nurse also uses the triage system independently to prioritize care. The most commonly used triage system used under usual conditions is the three-level model: emergent, urgent, and nonurgent. Emergent triage means that a condition exists to a pt that poses an immediate threat to a pt’s life or limb. Urgent triage means that the pt should be treated quickly, but that an immediate threat to life does not exist at the moment. Nonurgent pts can generally tolerate waiting several hours for health care services without a significant risk of clinical deteriorization. Urgent And Unscheduled Care Nursing Essay.

Some of the standards of care in the St. Nick’s ER involve quality improvement measures. Some measures implemented are care maps, discharge protocols, standing orders, and measurement tools designed to save lives and reduce healthcare costs by lowering recurrences. Also secondary prevention guidelines are also implemented. The ER has special emergency services protocol sheets that are referred to as pts come in to tell the nurse what would be done for each pt in specific situations, for example: burn pts, bleeding pts who are on coumadin, suspected meningitis, and asthma pts. As stated earlier, sometimes nursing diagnoses are noted if the pt is at high risk of injury. Otherwise, if a pt is being admitted to the hospital, nursing diagnoses are planned or implemented at this time.Urgent And Unscheduled Care Nursing Essay.  If the pt is admitted, the nurses will start to put together nursing diagnosis which will be planned, implemented, and evaluated when the pt moves a room in the hospital. An initial assessment including a full set of vitals is usually done upon arrival to the ER. Vitals including temp, pulse, blood pressure, resp, and O2 sat. After the initial assessment focus charting is done. This focuses on anything abnormal that was found and the reason why the pt has came in. Not all people who come in to the ER utilize it correctly. I observed a pt that has been coming in to the ER monthly for the past year for a toothache. I think this pt needs to see a dentist instead.

He stated he did not have insurance, but he did have medical assistance, in which there are a few dentists who accept this form of insurance. Another pt that came in to the ER ended up having a bruise from a fall 3 days prior. I think the pt just was looking for an excuse to get out of work. So, there are people who come in with problems that are either minor or could have waited so the pt could have been seen in the clinic the next day. According to our textbook, the most common reasons pts seek emergency care include chest pain, abdominal pain, headache, and fever. I did observe a few other pts who really did come to the ER for valid reasons. One lady was dehydrated from nausea and had severe orthostatic hypotension. Another pt came in with seizure-like symptoms. One man came in with chest pain. A 16 yr old came in by ambulance with possible neck and or spinal injuries from a car accident. These examples are of people who utilized the ER with real emergent situations. The emergency nurse also impacts the health of the community. One way is when people call in to the ER for advice on whether a pt should be brought in or not the nurse reviews the pts signs and symptoms and gives educated advice. Another way is by teaching. The ER nurse does a lot of teaching to pts who come in to the ER, especially to those who are not admitted to the hospital. The pts are educated on what kinds of signs and symptoms to be aware of depending on their situation, when to come back to the ER, if the pt needs to follow up in the next few days with their physician, and on the medications that may be prescribed. Urgent And Unscheduled Care Nursing Essay.

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The ER nurse is also trained to treat people for environmental injuries like poisonous bites and heat stroke and mass casualties like earthquakes and fire, so the ER nurse gives the community a sense of security to know medical personnel are there in case of injury. To support appropriate use of the emergency room, health care providers can advertise what kind of injuries and problems people could have to come in to the ER for treatment or assessment. Health care providers can also refer pts who call in on the phone first to go to the clinic the next day if a minor problem. When appropriate ER pts come in health care providers can boost their confidence levels by stating, “It’s good that you came in to be checked out.” Another way is teaching. Some pts may not even realize they are coming in to the ER for minor problems. Health care providers need to stress signs and symptoms that may be present for a pt to use the ER. The way the Wisconsin Good Samaritan Law is written is a little confusing due to the wording and the different interpretations of the meaning of the law. My understanding of the Good Samaritan Law is it states that any average citizen who gives emergent care at the scene of an accident will not be liable for his/her actions. But, if the person is trained in health care, like a nurse, he/she can not provide any services or cares beyond his/her training level or they could be liable for their actions. The law also does not state that any health care professional, including nurses have to stop to help at the scene of an accident (although it would be good of them to). Also, if health care professionals, including nurses, volunteer at school sponsored athletic events and render care to anyone before, during or immediately after the event, within the scope of their practice, they will not be liable as long as they are not being paid.Urgent And Unscheduled Care Nursing Essay.