Mediating the interface between voluntariness and coercion: A qualitative study of learning disability nurses' work in medical examinations of people with intellectual disability.

AIMS AND OBJECTIVES: To gain knowledge of prevention and use of restraints in provision of medical care to people with intellectual disability. To this end, we explore how learning disability nurses in community services support the individual through medical examinations when facing resistance. BACKGROUND: Despite increased focus on limiting restraints, there is a lack of knowledge of how restraints are prevented and used in the delivery of physical health care to people with intellectual disability. DESIGN: We used an ethnographic comparative case design (n = 6). METHODS: The study was carried out in Norway. The analysis is based on data from semi-structured interviews, participant observation and document studies, in addition to health sociological perspectives on how to support individuals to make their body available for medical examination and intervention. The SRQR checklist was used. RESULTS: Learning disability nurses strove to ensure that examinations were carried out on the individual's terms, supporting the individual in three phases: preparing for the examination, facilitating the examination and, when facing resistance, intervening to ensure safe and compassionate completion of the examination. CONCLUSIONS: Supporting the person was a precarious process where professionals had to balance considerations of voluntariness and coercion, progress and breakdown, safety and risk of injury, and dignity and violation. Through their support, learning disability nurses helped to constitute the "resistant" individual as "a cooperative patient," whose body could be examined within the knowledge and methods of medicine, but who could also be safeguarded as a human being through the strain of undergoing examination. RELEVANCE TO CLINICAL PRACTICE: The article sheds light on how restraints are used in the medical examination and treatment of people with intellectual disabilities and demonstrates the significance of professional support workers' contributions, both in facilitating safe and efficient medical care and in ensuring the least restrictive and most compassionate care possible.

Decreased level of consciousness in a child: recognition and management.

A child presenting with decreased level of conscious (dLOC) is of great concern due to the wide range of possible causes, and potential for death or serious long-term sequelae. It is therefore vital that health professionals can recognise a child with dLOC quickly, intervene appropriately and escalate for senior review as a matter of urgency. This article provides an explanation for the mechanisms of decreased consciousness, outlines the different causative pathologies, and provides a simple and logical approach to the first-line recognition and management that a health professional may apply when faced with such a patient. Illustrative case studies have been included, to demonstrate how children with dLOC may present in clinical practice.

How to care for adults with low back pain in the primary care setting.

Low back pain (LBP) is one of the most frequent patient complaints in primary care. This article discusses the assessment and treatment of patients with LBP, including nonpharmacologic and pharmacologic approaches.

"You'll have to be my eyes and ears": A conversation analytic study of physical examination on a health helpline.

AIMS AND OBJECTIVES: To explore the accomplishment of physical examination on a health helpline. By focusing on the ways in which callers are asked to examine themselves and report information to nurses, we aim to provide insight into how physical examination at a distance is achieved. BACKGROUND: Physical examination is a routine feature of healthcare encounters. In face-to-face settings, patients are subject to professional scrutiny through talk, touch and observation. Health professionals working on helplines face challenges in assessing signs of illness when they do not have physical access to patients. DESIGN AND METHODS: Conversation analysis was used to explore sequences of interaction between nurses and callers that involved physical examination. ANALYSIS: Analysis examined how physical examination was routinely accomplished in a helpline environment. Nurses typically guided callers in self-examination by drawing on gross categorisations that required reporting of large-scale characteristics of symptoms (e.g., whether a body part looked "normal"). Physical examination was also regularly accomplished by nurses through two-component speaking turns: a prefacing component that involved instructions about self-examination; followed by a second component that included an information-soliciting question. These practices resulted in callers successfully accomplishing physical examination, despite their lack of professional medical knowledge. CONCLUSIONS: This study identifies the communicative practices used by nurses to accomplish physical examination in helpline calls. Such practices involved asking questions that sought general, rather than specific, information and the prefacing of questions with simple instructions on how to undertake self-examination. RELEVANCE TO CLINICAL PRACTICE: Previous research indicates that physical examination in telehealth can be challenging, particularly in environments where clinicians need patients to examine themselves. This study identifies how nurses on a helpline manage this challenge. The findings highlight ways in which nurses can recruit patients to undertake tasks that would typically be undertaken by clinicians in physically co-present consultations.

A qualitative study of advanced nurse practitioners' use of physical assessment skills in the community: shifting skills across professional boundaries.

AIMS AND OBJECTIVES: To explore multiple perspectives on the use of physical assessment skills by advanced nurse practitioners in the UK. BACKGROUND: Physical assessment skills practices are embedded in advanced nursing practice roles in the UK. There is little evidence on how these skills are used by advanced nurse practitioners in the community. DESIGN: Case study. METHODS: A qualitative interpretative single-embedded case study of 22 participants from South of England. A framework method analysed interview data collected by the researcher between March-August 2013. Participants included nurses, doctors, nurse educators and managers. FINDINGS: Physical assessment skills education at universities is part of a policy shift to develop a flexible workforce in the UK. Shared physical assessment practices are less to do with role substitution and more about preparing practitioners with skills that are fit for purpose. Competence, capability and performance with physical assessment skills are an expectation of advanced nursing practice. CONCLUSIONS: These skills are used successfully by community advanced nurse practitioners to deliver a wide range of services in response to changing patient need. The introduction of physical assessment skills education to undergraduate professional preparation would create a firm foundation to develop these skills in postgraduate education. RELEVANCE TO CLINICAL PRACTICE: Physical assessment education prepares nurses with the clinical competencies to carry out healthcare reforms in the UK. Shared sets of clinical assessment competencies between disciplines have better outcomes for patients. Levels of assessment competence can depend on the professional attributes of individual practitioners. Unsupportive learning cultures can hinder professional development of advanced nursing practice.

Physical health monitoring in mental health settings: a study exploring mental health nurses' views of their role.

AIMS AND OBJECTIVES: To explore nurses' views of their role in the screening and monitoring of the physical care needs of people with serious mental illness in a mental health service provider. BACKGROUND: There is increasing awareness through research that people with serious mental illness disproportionately experience and die early from physical health conditions. Mental health nurses are best placed as front-line workers to offer screening, monitoring and interventions; however, their views on physical care interventions are not studied often. DESIGN: Qualitative exploratory study. METHODS: The study was carried out in a mental health inpatient centre in England. Volunteer sampling was adopted for the study with a total target sample of (n = 20) nurses from three inpatient wards. Semistructured interviews were conducted with (n = 10) registered mental health nurses who had consented to take part in the study. Inductive data analysis and theme development were guided by a thematic analytic framework. RESULTS: Participants shared a clear commitment regarding their role regarding physical health screening and monitoring in mental health settings. Four themes emerged as follows: features of current practice and physical health monitoring; perceived barriers to physical health monitoring; education and training needs; and strategies to improve physical health monitoring. CONCLUSIONS: Nurses were unequivocal in their resolve to ensure good standard physical health monitoring and screening interventions in practice. However, identified obstacles have to be addressed to ensure that physical health screening and monitoring is integrated adequately in everyday clinical activities. Achieving this would require improvements in nurses' training, and an integrated multiservice and team-working approach. RELEVANCE TO CLINICAL PRACTICE: Attending to the physical health needs of people with serious mental illness has been associated with multiple improvements in both mental and physical health; nurses have a vital role to play in identifying and addressing causes of poor physical health to improve physical health outcomes in people with serious mental illness.

Use of Daily Interruption of Sedation and Early Mobility in US Hospitals.

Although the Awakening and Breathing Coordination, Delirium assessment, and Early exercise/mobility (ABCDE) bundle may be effective, individual components of ABCDE may not be implemented as intended. We examined the use of daily interruption of sedation (DIS) and early mobility, looking for an association between these bundle elements. Despite the growing use of DIS and early mobility, the two do not seem to be adopted together, with serious implications for the effectiveness of the ABCDE bundle.

Multidrug-resistant bacteria infection and nursing quality management application in the department of physical examination.

The main problem of clinical prevention and control of multi drug resistant bacteria infection is to strengthen the monitoring of pathogenic bacteria spectrum, this study research on the multi drug-resistant bacteria infection and nursing quality management application in the department of physical examination. The results of this study showed that the number of patients with multiple drug resistant infections showed an increasing trend. Therefore, once the patients with multiple drug-resistant bacteria infection are found, the prevention and control of the patients with multiple drug-resistant bacteria should be strictly followed, and the patient's medication care should be highly valued. Also, the nurses need to be classified based on the knowledge and skill characteristics of the nurses in the department of physical examination, and compare the nursing effect before and after classification and grouping. The physicians and individuals receiving physical examinations in the department of physical examination had a higher degree of satisfaction for nursing effect after classification compared with those before classification. Classification and grouping management helps improve the nursing quality and overall quality of the nurses in the department of physical examination.

Nursing physical assessment for patient safety in general wards: reaching consensus on core skills.

AIMS AND OBJECTIVES: To determine consensus across acute care specialty areas on core physical assessment skills necessary for early recognition of changes in patient status in general wards. BACKGROUND: Current approaches to physical assessment are inconsistent and have not evolved to meet increased patient and system demands. New models of nursing assessment are needed in general wards that ensure a proactive and patient safety approach. DESIGN: A modified Delphi study. METHODS: Focus group interviews with 150 acute care registered nurses at a large tertiary referral hospital generated a framework of core skills that were developed into a web-based survey. We then sought consensus with a panel of 35 senior acute care registered nurses following a classical Delphi approach over three rounds. Consensus was predefined as at least 80% agreement for each skill across specialty areas. RESULTS: Content analysis of focus group transcripts identified 40 discrete core physical assessment skills. In the Delphi rounds, 16 of these were consensus validated as core skills and were conceptually aligned with the primary survey: (Airway) Assess airway patency; (Breathing) Measure respiratory rate, Evaluate work of breathing, Measure oxygen saturation; (Circulation) Palpate pulse rate and rhythm, Measure blood pressure by auscultation, Assess urine output; (Disability) Assess level of consciousness, Evaluate speech, Assess for pain; (Exposure) Measure body temperature, Inspect skin integrity, Inspect and palpate skin for signs of pressure injury, Observe any wounds, dressings, drains and invasive lines, Observe ability to transfer and mobilise, Assess bowel movements. CONCLUSIONS: Among a large and diverse group of experienced acute care registered nurses consensus was achieved on a structured core physical assessment to detect early changes in patient status. RELEVANCE TO CLINICAL PRACTICE: Although further research is needed to refine the model, clinical application should promote systematic assessment and clinical reasoning at the bedside.

Physical assessment techniques performed by Italian registered nurses: a quantitative survey.

AIMS AND OBJECTIVES: The aims of the study were to describe which of the core techniques of the physical assessment are regularly performed by a sample of Italian nurses, and to investigate the potential predictors of a more complete examination. BACKGROUND: Physical examination is among the essential tasks of nursing professionals, who are requested to perform a correct and complete physical assessment. DESIGN: Cross-sectional survey. METHODS: The study was performed between August 2013 and January 2014 in 17 Italian regions. A total of 1182 questionnaires were collected. RESULTS: Most participants were females (age range 41-50 years), and worked in Internal Medicine, Intensive Care and Surgical hospital units. Of the 30 core techniques that are currently taught and performed according to the Italian Baccalaureate degree requirements, 20 were routinely performed, 6 were seldom used and 4 were learnt but almost never performed (auscultation of lung, heart and bowel sounds and spine inspection). Graduate and postgraduate nurses, working in Intensive Care Units and Nursing Homes, were more prone than the others to carry out a more complete physical assessment. CONCLUSIONS: The skills to perform a physical assessment are suboptimal among this sample of Italian nurses. Health and educational providers should pose more attention and efforts to provide nurses with an acceptable training in physical examination practice. RELEVANCE TO CLINICAL PRACTICE: This study describes the specific physical techniques performed by nurses in real practice and provides information on which skills require more attention in nursing educational programmes.

A concept analysis of oral hygiene care in dependent older adults.

AIM: To report a concept analysis of oral hygiene care. BACKGROUND: Oral hygiene care, as it is provided to older patients in hospital and long-term care settings by nurses and their delegates, has the potential to contribute to the oral health of patients while preventing aspiration pneumonia as well as periodontitis, which itself has been associated with several systemic diseases. However, the state of oral cleanliness in such patients tends to be poor and despite the existence of guidelines, nursing care practices may be inadequate and not reflective of recent advances in knowledge. DESIGN: Concept analysis. DATA SOURCES: A search of electronic databases (2002-2012), use of internet search engines, and hand searching yielded an international data set of 66 research studies, reviews, and practice guidelines. REVIEW METHODS: The concept analysis method of Walker and Avant was used to explore the concept of oral hygiene care in the context of frail older patients. RESULTS: Oral hygiene care involves approaches informed by knowing the patient, inspecting the oral cavity, removing plaque, cleansing the oral tissues, decontaminating the oral cavity, using fluoride products and maintaining oral tissue moisture. Those attributes, along with their antecedents and consequences, form a conceptual framework from which a middle-range theory of nurse-administered oral hygiene care is derived that could be tested, evaluated, modified, and translated into practice. CONCLUSIONS: Clarity around the concept of oral hygiene care as a nursing intervention could enable nurses to impact oral health outcomes and possibly prevent systemic diseases in older patients.

The use of physical assessment skills by registered nurses in Australia: issues for nursing education.

The purpose of pre-service nursing education programs is to prepare competent graduates who are able to function as safe, professional registered nurses. An extensive element of these programs is the teaching of physical assessment skills, with most programs educating students to perform over 120 such skills. Previous research from North America suggests that the majority of skills taught to nurses in their pre-service programs are not used in practice. As part of a larger study, an online survey was used to explore use of 121 physical assessment skills by Australian nurses. Recruitment occurred via mailed invitation to members of the Australian Nursing Federation. Data were extracted from 1220 completed questionnaires returned by nurses who were mostly employed in New South Wales, were female and experienced nurses. Respondents indicated that they used only 34% of skills routinely. Results reinforce evidence found in the literature that many of the skills taught to nurses are either not used at all (35.5%) or are used rarely (31%). These findings have implications for the teaching of physical assessment skills in pre-service nursing programs, and raise questions about the value of extensive skills teaching in the context of contemporary health care. Further research into barriers to the use of physical assessment skills in nursing and the need for comprehensive skills preparation for the generalist nurse is likely to offer some solutions to these questions.

[Taking the temperature, a procedure which should not be trivialized]. / La prise de la température, un geste a ne pas banaliser.

Along with blood pressure, temperature is one of the fundamental parameters most frequently measured by nurses in their daily practice. Different sites of the body are suitable. They are reviewed here with their respective methodologies, advantages and disadvantages in order to adapt nurses' clinical practice as best as possible.

Opportunistic screening for skin cancer using a mobile unit in Brazil.

BACKGROUND: Skin cancer is the most common malignancy in the white population worldwide. In Brazil, the National Cancer Institute (INCA) estimates that in 2010 there will be 119,780 and 5,930 new cases of non-melanoma skin cancer and melanoma, respectively. The aim of this study was to evaluate the use of a mobile unit in the diagnosis and treatment of skin cancer in several poor regions of Brazil. METHODS: The diagnosis of skin cancer was accomplished through active medical screening in the prevention Mobile Unit (MU) of Barretos Cancer Hospital (BCH). The study population consisted of patients examined in the MU between 2004 and 2007, and their suspicious lesions were subjected to histopathological evaluation. Data were collected prospectively from standardized forms and analyzed. RESULTS: During the screening, 17,857 consultations were carried out. A total of 2012 (11.2%) cases of skin cancer were diagnosed. The predominant histological type reported was basal cell carcinoma (n = 1,642 or 81.6%), followed by squamous cell carcinoma (n = 303 or 15.1%), Bowen's disease (n = 25 or 1.2%), malignant melanoma (n = 23 or 1.1%), basosquamous cell carcinoma (n = 3 or 0.1%), miscellaneous lesions (12 or 0.6%), and metatypical carcinoma (n = 4 or 0.2%). Only 0.6% of lesions were stage III. There were no stage IV non-melanoma skin lesions, as well as no melanomas stages III and IV, found. CONCLUSIONS: It was observed that the MU can be a useful tool for early skin cancer diagnosis and treatment. This program probably is important, especially in developing countries with inadequate public health systems and social inequality.

Comparison of temporal artery to rectal temperature measurements in children up to 24 months.

This descriptive study compared temporal artery (TA) and rectal temperature measurements, patient comfort during temperature measurements, and nursing time required to obtain temperature measurements. Study participants (n = 40) included children 0-24 months old with fever higher than 38°C, admitted to a freestanding children's hospital in the Midwest. Statistical analysis of 450 paired TA and rectal temperature measurements revealed a 0.776 correlation, mean difference of 0.03°C, and 94.7% of measurements differing by less than 1.0°C. Patient comfort, measured via the Face, Legs, Activity, Cry, Consolability Scale, was enhanced with TA thermometry compared to rectal. TA thermometry resulted in an 87% savings of nursing time.

Advanced physical assessment skills: implementation of a module.

This article aims to explore and examine advanced physical assessment skills and the role of the district nurse. It will particularly highlight district nurses' perceptions of how they may implement skills learnt on a new module introduced into the Community Health Care Nursing degree at a university in London. Physical assessment skills have traditionally been viewed as part of a doctor's role; however, with the advancement of nursing roles, it is argued that it has become a key nursing skill. As Government policy continues to expect health professionals to keep patients in the community who have complex health and social care needs, the role of the district nurse presents as 'best placed' to take on this challenge (Department of Health (DH), 2005a; 2005b). Evaluation of the district nurses' perceptions of their practice is shared here, highlighting some of the challenges that they face. The article will address the complexity of developing a curriculum in response to the DH initiatives and the importance of listening to students on courses.

Identifying non-viral gynaecological conditions.

The role of emergency nurse practitioners (ENPs) is constantly changing as their caseloads expand, from comprising patients with minor injuries and ailments to comprising those with more complex medical and surgical conditions. This article discusses three common gynaecological infections with which women may present to emergency departments: vulvovaginal candidiasis, bacterial vaginosis and trichomoniasis. Knowledge of these conditions, and of how to obtain accurate histories and conduct brief patient examinations, is needed if ENPs are to diagnose and provide treatment for them.

CE: Assessing Back Pain in Patients Presenting to the ED.

ABSTRACT: Although back pain is common, most often benign, and generally resolves in a few days with self-care, nonspecific low back pain that does not resolve with self-care and prompts patients to seek treatment in an ED may result from a serious underlying pathology. In this article, the first in a series on clinical red flags-indicators that can be used in the clinical setting to screen for an elevated risk of severe underlying conditions-the author considers back pain manifestations that may signal the presence of a debilitating or even fatal disease process. Detecting such red flags and communicating their presence to the attending provider can facilitate appropriate diagnosis and management.