For the last couple of weeks, I have been reading in preparation for my Acute Illness Management course (Greater Manchester Critical Care Skills Institute, 2014).  I have covered chapters on caring for acutely ill patients who have respiratory problems, hypotension, severe sepsis, a poor urine output, an altered level of consciousness and acute pain.  As well as learning about the specifics of each condition, a common systematic assessment method of ABCDE was applied to each.  Acute illness management is extremely important, because, historically, there have been failures in measuring and recording basic routine observations, in recognising when vital signs get worse, and therefore a delay in responding to deteriorating patients appropriately and timely (National Patient Safety Agency, 2007).

Yesterday, I attended a series of lectures and workshops which related to each of the above conditions and the assessment process in more detail.  An assessment demonstration of a patient was given, followed by a chance to practise, and watch others practising assessment.  Finally, I was individually assessed in carrying out an ABCDE assessment on an acutely ill ‘patient’ mannequin, and also had to take a written test too.  The practical test was extremely nerve-wracking and there was a lot to remember, but fortunately for me, I was able to pass on both of the elements.  Hereby follows an overview of what an ABCDE assessment involves, in order for me to reflect upon and consolidate my learning.

Initially, wherever possible, information on the patient’s situation and background must be handed over to the assessing nurse.  This should include their name, age, what has currently happened to them, and a brief overview of their medical history, including known drug allergies, and previous diagnoses.

AIRWAY: A patient’s airway MUST be patent and maintained before anything else can be done – if the patient cannot get oxygen into their body, they will soon die from hypoxia.  An easy way to check the airway is to speak to the patient, and if they can talk back this is a positive sign.  Thinking about the patient in terms of AVPU – Alert, Voice, Pain or Unresponsive – if the person is in the Pain or Unresponsive stage, their airway is likely to need some assistance, such as an oropharyngeal airway, and may also benefit from repositioning onto their side.


Alternatively, the patient may have an obstruction in their mouth and may require some suction.  If there are any noises, such as snoring, crowing, gurgling or stridors, these are likely indicators of an obstruction, while a crackling noise may indicate pulmonary oedema (fluid on the lung).  If a patient has pulmonary oedema, it is important not to give them fluids, as they may drown internally.  A see saw chest and abdomen movement, where the chest moves inwards and the stomach moves out, is likely to indicate a complete airway obstruction.

Once the airway is patent, the patient may require some breathing assistance, and so their oxygen saturations should be checked to determine their O2 levels.  A 15 litres per minute non-rebreather high concentration oxygen mask should be applied, if required.  The bag should be inflated by two-thirds before putting onto patient.  Normal O2 levels are 94-98%, or 88-92% for a person with Chronic Obstructive Pulmonary Disease.

oxygen mask

BREATHING: Once the airway has been properly attended to, the breathing can now be assessed.  Look at the depth, rate and rhythm of the breathing.  Is the respiration in the normal range of 12-20 per minute?  Or is it raised or decreased?  An increased respiratory rate is an early indicator of deterioration, and the patient will soon get tired from continued tachypnoea.  Look for symmetry in the chest movement.  Is the patient struggling to breath and having to use accessory muscles, such as the shoulders?  Consider sitting the patient upright with pillows, as it will be more difficult for them to breath when lying flat on their back.  Look at the patient’s colour, and determine whether it is healthy, pale or cyanosed.  A good indicator of central cyanosis is a blue-tinged tongue, or blueness inside of the lips.  If oxygen has not already been considered, now is an opportunity to determine the oxygen saturations, and to apply a 15 litres per minute high concentration oxygen mask, if required.

CIRCULATION: Once the breathing has been addressed, the circulation can now be assessed.  Starting at the tips of the fingers, check the capillary refill time by depressing the finger tip for 5 seconds.  Does the blood return at a normal rate of about 2 seconds, or is it increased or decreased?  Moving on to the radial pulse (on the wrist), is it in the normal range of about 80-100, or is it raised or slow?  Is the heart rate strong and bounding, or is it weak and thready?  Moving up the arm, is there a wide bore cannula in situ and patent, or does that need to be attended to later?  Does the manual blood pressure fall within the normal range?  120/80 mmHg is ideal, but anything between 90/60 mmHg to 140/90 mmHg may be acceptable (NHS Choices, 2015).  If a patient has baseline measurements, these are really useful for making informed comparisons of what is normal for them.  Do not use electronic dynamap machines when patients are acutely unwell, as they are likely to be inaccurate or will result in an error message.


Moving up to the underarm (axillary), is the patient’s temperature normal, pyrexic or low?  This should ideally be about 36.5˚C.  Moving across and down to the stomach area, consider whether the patient has a normal urine output, or is there no information on this?  A normal output is about 0.5 ml/kg/per hour, so should therefore be about 35 ml for a 70 kg patient.  Consider putting the patient onto a fluid balance chart for monitoring.  If the heart rate is higher than the blood pressure, consider giving fluids to rectify the readings.  250 ml of 0.9% sodium chloride IV over 5-10 minutes is standard.  Once the fluid is administered, any changes in pulse and blood pressure should be reassessed, and then another 250 ml can be given, if necessary.  Once all the circulation checks are complete, bloods can be taken from the cannula site, and should generally include a Full Blood Count, Urea and Electrolytes, INR for clotting and Glucose.  If the patient has a high temperature, blood cultures should be taken to check for sepsis infection, and in the case of sepsis, IV antibiotics would need to be administered too.  Once the bloods are obtained, the IV fluid or antibiotics can then be administered via the site.

blood tubes


*****Throughout the whole assessment process, it is important to keep going back to check on the previous stages.  For example, if an oropharyngeal airway was used in an unconscious patient to maintain the airway, and the patient becomes conscious, the airway adjunct will need to be removed.  If the patient is using an oxygen mask however, this should be kept on until the doctor arrives; although oxygen saturations should be periodically checked.

DISABILITY: An excellent mnemonic to remember this stage is GAPPS. G – Glucose – does the patient have normal blood glucose readings between 4-7 mmol/l, or are they presenting as hypo or hyper-glycaemic?  If hypoglycaemic, IV dextrose will be required.  If hyperglycaemic, insulin will be required, although this would need prescribing by a doctor.  A is AVPU – Alert, Voice, Pain, Unresponsive – how is the patient doing? Are there any improvements?


P – Pupils – when a light is shined in a sweeping moment across each eye, do the pupils constrict ordinarily in reaction to the light, or are they dilated and possibly indicative of drugs?  Does one pupil constrict and the other dilate?  Unilateral responses could be a sign of neurological injury (Patient, 2015).

pupil light pen

P is also for pain.  Is there any indication of pain in the patient?  If so, a doctor will need to prescribe an appropriate level of pain relief.  Finally, S is for seizures.  Has the patient had any seizures?  If they are prolonged or recurrent, the usual treatment is rectal diazepam (Epilepsy Action, 2015).

WHO analgesic ladder

EXPOSURE: The physical assessment concludes with a head to toe examination of the patient, front and back, in order to ensure that nothing abnormal has been missed, such as wounds/trauma, rashes, swelling or dryness.  Once this is finished, it is important to go back to the earlier stages again, and make sure that everything is stable or improving.

Once the doctor arrives, it is essential that the assessing nurse hands over the full information of what has been done, including the patient’s initial presentation and background, the assessment findings, and any actions taken.  The nurse needs to ask the doctor for a management plan and also for further prescriptions of oxygen, fluid, pain relief, insulin, etc.  A useful tool for communicating information accurately is the SBAR model – Situation, Background, Assessment and Recommendations.


References and Further Reading

Epilepsy Action. (2015). Status epilepticus. Retrieved 21st November, 2015, from

Greater Manchester Critical Care Skills Institute. (2014). Acute Illness Management (5th ed.). Greater Manchester: Critical Care Skills Institute.

National Patient Safety Agency. (2007). Safer care for the acutely ill patient: learning from serious incidents. Retrieved from

NHS Choices. (2015). Your NHS health check results. Retrieved 21st November, 2015, from

Patient. (2015). Pupillary abnormalities. Retrieved 21st November, 2015, from

Research report

The summer has gone by so quickly, as I have been hard at work on a 6000 word evidence-based practice research report.  The question of the report was concerned with how nurses can encourage personal care in people with dementia, as it is something that I have occasionally found challenging in my part-time job as a care assistant and as a student nurse.  The topic is one that fascinates me greatly, and one that I have enjoyed reading around in detail.

The structure of the research report has been a learning curve, concerned with familiarising myself with established ways of conducting research and literature reviews.  After deciding on a topic area, the first thing that I did was to carry out a scope search, just to get an idea of what literature existed, and in what quantities.  My topic choice fortuitously had plenty of relevant literature, and I was quickly able to move on to carrying out searches in databases, and refining them down to just 10-20 research papers.

Reading and critically appraising each individual paper was a massive and lengthy task.  I utilised the standard CASP tools, but also found some other research design specific tools, which were often useful in different ways.  Once all the analyses were complete, I collated my findings for comparison, and started my appraisal and discussion using themed headings.

The process has increased my research vocabulary extensively, and I am now familiar with the main types and features (advantages and disadvantages) of research designs: quantitative, qualitative and mixed-method.  I have also adopted new words and phrases such as triangulation, attrition, phenomenology, grounded theory, the Hawthorne effect and bracketing, to name just a few.  I will not go into individual explanations of each here, as you may well know them already; or if not, there are some excellent research publications available that can explain them clearly and succinctly.  One of the most useful ones, in my opinion, is: Parahoo, K. (2006). Nursing research: principles, process and issues (2nd ed.). Basingstoke: Palgrave Macmillan.

Now that my report is just about complete, I can testify that the process was lengthy, repetitive at times, but yet highly interesting and instructive.  I am glad that I have learnt about the process of carrying out research, and why it is so important to furthering nursing knowledge.

I am now looking forward to the second placement of the third, and final, year of my training, and also need to start work on another 6000 word report!  My new piece of work appears to be more manageable, as it is broken down into three parts, but it is not necessarily any easier than the last.  I need to give it my full attention, as it contributes to a weighty chunk of my final degree classification, and will also help me to develop final semester knowledge on leadership and management as a newly qualified nurse.

CASP UK. (2013). Critical Appraisal Skills Programme. Making sense of evidence. Retrieved from

Hearing Difficulties

action on hearing loss

This week I have been finding out about hearing difficulties.  I have discovered that the main reasons for hearing loss are either sensorineural or conductive.

Sensorineural hearing loss occurs when either (or sometimes both) the hairs of the inner ear or the auditory nerve are damaged.  The latter is responsible for sending sound messages to the brain.

Conductive hearing loss occurs when the ear is blocked, usually due to earwax or glue ear.

ear diagram


After repeated exposure to loud noises, such as excessively high volume music or work-related drilling and banging, the hairs of the inner ear can become damaged and flattened, or the auditory nerve itself may be damaged.  Additionally, the ageing process will also tend to produce a similar type of decline, but more gradual, from around the age of 40.  By later life, the hearing loss will tend to be very noticeable, and hence problematic.

Other less common and lesser known causes of hearing loss include: gene inheritance; infection complications from mumps, measles or rubella; Meniere’s disease – a combination of vertigo, tinnitus (ringing in the ears) and ear blockage; stroke and cardiovascular damage; the side-effects of some medications, such as antibiotics and cancer treatments; plus a benign growth, on or near to the auditory nerve, called an acoustic neuroma.

In the case of sensorineural hearing loss, an MRI scan will usually be taken, mainly to rule out the complications of an acoustic neuroma being present.  Although acoustic neuromas are small and slow growing, if they get larger they will produce symptoms such as dizziness, tinnitus and balance disturbances, or sometimes complications such as hydrocephalus (water on the brain).  Treatment would either be via surgery or radiation.  A hearing aid will also usually be offered for sensorineural hearing loss.

hearing aid types

Hearing aids are available free of charge on the NHS, and usually tend to be very good quality digital models.  Maintenance and batteries are also completely free for life.  Hearing aids will either be behind the ear (BTE), in the ear (ITE), in the canal (ITC) or completely in the canal (CIC).  The behind the ear hearing aids are standard NHS provision and come in a choice of discreet beige, brown or silver, although some brighter colours are available on request.  The other types of hearing aid, including the ‘invisible’ type, must be privately sourced by individuals, and tend to be quite costly (starting at around £300 for a single hearing aid, rising to as much as £3500 for a pair).  However, as NHS hearing aids are now more up-to-date, and of a very good quality, they are apparently much more acceptable to the majority of service users.  Two good quality hearing aid leaflets are available from Action on Hearing Loss, via

hearing aid

Typical NHS model


After repeated build-up of ear wax, an accumulation of fluid or ear infections, conductive hear loss will be the result.  Less commonly, it may also be caused by a perforated ear drum or otosclerosis, an abnormal bone growth in the middle ear.

Conductive hearing loss is usually reversible by simple procedures such as removal of ear wax, medication or minor surgery.

Further support

Here in the UK, people with long-term hearing problems can seek further support and advice from the charity Action on Hearing Loss (formerly the Royal National Institute for the Deaf) and may even receive animal assistance from Hearing Dogs for Deaf People.

hearing dogs

Further References

Action on Hearing Loss. (2015).

Hearing Dogs for Deaf People. (2015).

National Health Service Choices. (2015). Hearing Aids. Accessed 25 June, 2015, from

National Health Service Choices. (2015). Hearing Loss. Accessed 25 June, 2015, from

Patient Information. (2015). Acoustic Neuroma. Accessed 25 June, 2015, from

Patient Information. (2015). Otosclerosis. Accessed 25 June, 2015, from

Patient Information. (2015). Perforated Eardrum. Accessed 25 June, 2015, from

Hobbies and relaxation are essential for good mental health

When taking time to enjoy the weekend, I realised the importance of hobbies and general relaxation for promoting and maintaining good mental health.  Without time to switch off from our busy working lives, our stress levels can increase and, over time, can potentially remain at a constant high; this is very damaging for our health, in terms of weakened immunity, poor sleep, changes in appetite, hormonal changes, increased blood pressure and cardiovascular health, coupled with poor coping strategies such as excess alcohol intake.  The overall danger of long term unchecked stress is that it also increases the risk of depression, cancers and cardiovascular problems.  It is therefore somewhat essential that we take time out to pursue hobbies that we enjoy, in order to relax and look after our mental health.

My favourite way to unwind is, undoubtedly, by reading books.  For purposes of relaxation, my reading material has to be fiction; non-fiction books are what I associate with study.  My chosen areas of fiction are very diverse, and range across titles such as Thomas Hardy’s Tess of the D’Urbervilles, the Scandinavian noir of Henning Mankell’s Wallander series, Jeffrey Archer’s Clifton Chronicles, George R. R. Martin’s Game of Thrones series to Susan Hill’s Simon Serrailler series.  Reading is a fantastic hobby that can transport you virtually anywhere; the pure escapism is wonderful and very hard to beat.  I established myself as a ‘bookworm’ from a very young age, and it is a love that has never abandoned me, and has helped to keep me sane!  Non-fiction books additionally serve me well, but the intellectual stimulation that they produce requires more concentration, and are hence less of an easy read.  Intellectual stimulation is good however, and for me is essential for a healthy state of mind.

susan hill   thomas hardy   mankell

The other way that I relax is by walking with my Basset Hound dogs.  Research has repeatedly shown that spending time with dogs is good for our mental health, as well as physically reducing our blood pressure levels through stroking and interaction.  As well as making loyal pets and companions, our canine friends are used as pat dogs for the elderly and for people living with dementia.  For me, it is my dogs’ qualities of loyalty, unconditional love, and the humour that they bring that makes them special; I cannot imagine a home and a life without dogs.  I also love the essential exercise through walking that accompanies owning a dog.  Walking is a great way to relax, to improve general mood and physical well-being.  Walking can also be an effective way to maintain or reduce weight.  Daily dog walks additionally allow people (and dogs) to connect with other people, whether they are other dog walkers, or neighbours / local residents.  Meeting other people is good for the mind, as it guards against isolation and strengthens our support networks.

barney basset

As well as having dogs, I also share my home with a beautiful Horsefield tortoise.  The tortoise’s dietary requirements form part of the daily dog-walking routine, as it is an excellent opportunity to gather fresh vegetation, such as dandelions, clover, grass and so forth.  The tortoise also shares many of my own vegetable dietary components, but there is nothing quite like being in touch with nature and gathering free food from the surrounding countryside.


Although not one of my regular hobbies, this weekend I re-discovered the simple pleasures that can be gained from sharing ‘childhood’ box games with family or friends.  For a rush of competitive adrenaline, I find the best game is Frustration (sometimes called Pop-up); while for a longer more considered game, I personally enjoy Monopoly, draughts or Scrabble.

frustration game

Whatever your choice of hobby or pastime, it does not really matter, just so long as it is relaxing.  Working, resting and playing are all equally important, and can all be beneficial for our overall brain and body health.

Transition from student to nurse

Last week I completed my university module concerning preparation for role transition – from student to becoming a nurse.  It culminated with my delivery of a 20 minute power point presentation, which reflected on my learning journey – where I was at the beginning, where I am now and where I need to get to.  There were certain criteria which had to be met, and hereby follows an outline of the main material that I covered.

Choosing and using a reflective framework was the key requirement, and the one that I used was Gibbs (1988).  I like the way that the headings prompt and guide the reflective process, and I particularly like the Action Plan stage, because past learning is used to inform future learning too.

reflective cycle

I used Gibbs Reflective Cycle to frame all of my presentation, and directly used the headings and order as illustrated above, e.g. description, feelings, evaluation, and so forth.

Another key requirement was to carry out self-assessments in order to determine my learning needs.  I used the Honey and Mumford Learning Styles Questionnaire (1992) (- reflector, theorist, activist and pragmatist), the VARK 80 item questionnaire (visual, auditory, reading and writing, kinaesthetic), a Key Skills (2003) assessment and the NMC (2010) Standards for Pre-registration Nursing.


The results of all these self-assessments were collated into a SWOT analysis – strengths, weaknesses, opportunities and threats.  The weaknesses were then used to create SMART goals – specific, measurable, achievable, relevant and time-bound, and propositions of how these goals would be achieved.


Besides these basic requirements, a discussion of role transition was also included.  The work of Duchser (2012) was used to illustrate the three stages of role transition within the first year of becoming a nurse; with transition shock taking place in the first 3-4 months of becoming a nurse, followed by a middle stage of lots of new learning and knowledge acquisition, then a final few months of finding stability and settling down.

The presentation was a personal challenge, because I am not a natural public speaker.  I enjoyed putting the slides together however, and I practised presenting them a few times each day for a couple of weeks before the actual day.  I am glad that I had the courage to approach the challenge, but am now looking forward to commencing my next piece of assessed work – a 6,000 word report on evidence based practice, which is something that I am more familiar and comfortable with.


Chartered Institute of Personnel and Development. (2015). SWOT analysis factsheet. Retrieved 17 May, 2015, from

Department for Education and Skills. (2003). Skills Strategy White Paper- 21st Century Skills: realising our potential. Cm 5810 The Stationery Office.

Duchser, J. B. (2012). From Surviving To Thriving: Navigating the First Year of Professional Nursing Practice (2nd ed.). Canada: Nursing the Future.

Gibbs, G. (1998). Learning by Doing: A Guide to Teaching and Learning. London: FEU.

Honey, P., & Mumford, A. (1992). The manual of learning styles (3rd ed.). Maidenhead: Peter Honey.

Nursing and Midwifery Council. (2010). Standards for Pre-registration Nursing Education. Retrieved from

VARK Questionnaire Version 7.1 Retrieved 17 May, 2015, from

Choosing how to die

As a 54 year old British man recently chose to end his life in a Swiss Dignitas clinic, the debate over assisted dying has reignited once again.  The media have documented, how the gentleman, Jeffrey Spector, was afraid that an inoperable tumour, growing on his spine, would cause him to become paralysed and dependent upon others.  Many people have felt that the father of three took his life too soon, and that there was always a chance that he would not become paralysed at all.  For others however, it was felt that Mr. Spector had made the right decision, and was extremely brave to do so.  Regardless of the split in opinions that exist, this gentleman was able to end his life exactly how he chose.  With foresight of the reactions, Jeffrey Spector was quoted as saying, ‘Some people will criticise me, but do not judge me.  Never judge anyone unless you have worn their shoes.’  People generally have some degree of choice in how they live their lives, so surely they should also be able to make some choices with around how they die.

In response to Mr. Spector’s story, many people have recently contacted the media, and have courageously shared personal accounts of how they helplessly watched family members die, while enduring pain and a low quality of life.  Most of these people expressed how they wished assisted dying had been a viable option for their loved one.  In the United Kingdom however, it still remains an illegal issue.

Discussion, over the last week, has inevitably compared human end of life care options to those available to our pets.  If euthanasia for people was legalised however, parts of the public still state reservations about where the boundaries of decisions should lie, and how issues of capacity should be guided and dealt with; for example, a person living with late stage dementia.  Naturally, there are some huge ethical considerations, but if clear guidance was put in place, there is surely possible scope for a suitable assisted dying bill.

Most nurses choose to go into the profession, in order to help make people well again; but for a smaller, yet significant, amount of nurses, their job is to help the dying, whether this is through providing comfort at the culmination of a natural elderly lifespan, or through a degenerative or terminal illness.  Nurses, working in environments such as hospices or as part of organisations like Macmillan, do a fantastic and valuable job; and, arguably, it takes a special kind of person to fulfil that role well.

Death can be a discomforting subject, and I am still personally unsure what I feel, deep down, about assisted dying.  I do know, however, that people need to talk more openly about end of life and palliative care, because if they succeed in avoiding discussion entirely, death will eventually become inevitable, either for themselves or a loved one.  No, it is not a nice thought, but as humans we are not immortal.  Yes, of course, our main focus should be on living our lives to the full and best of our abilities; however, a comfortable death, with some degree of choice, should also warrant some focus in bringing about life’s conclusion.

Drug and Alcohol Detox

Drinking effects

I have found myself back in a drug and alcohol detox placement; an environment that I have not worked in for over two years.  It is amazing though how the range of medications, and associated physical health issues, have resurfaced from the recesses of my brain, usefully emerging to help me with my learning within the workplace.

For alcohol detox, usually over 7 days, patients withdraw using a drug called chlordiazepoxide (Librium), which is gradually reduced.  In order to reduce cravings, a drug called acamprosate (Campral) is also given during the detox, plus also during the period when the patient goes home.  For a patient who weighs less than 60 kg, a slightly lower dose of acamprosate will be given.

People who have drank heavily are usually deficient in essential vitamins, caused by a poor diet and alcohol destroying vitamin B levels.  Patients may be experiencing neuropathy in their fingers and toes – a kind of pins and needles feeling.  They may also be experiencing myopathy – a muscle weakness in their arms and legs, which might even be effecting their mobility.  Additionally, they may also be experiencing short term memory problems.  In order to replenish the body therefore, patients are usually given three Pabrinex intra-muscular injections – one injection daily for three days; although in very heavy drinkers whose health has been compromised even further, two injections over three days, making a total of six, may alternatively be given.  Pabrinex is a nourishing liquid medication of vitamin B and C.  In order to maximise the bodily effects even further, patients are also given vitamin B and thiamine tablets, and are encouraged to carry on taking these when they get home.

For heroin detox, patients withdraw using liquid methadone.  It is a gradually reducing regime over 14 to 28 days, depending upon the amount of heroin that was previously being used.  In order to help with withdrawals, a drug called lofexidine (Britlofex) is also given; but before administering, the patient’s pulse should be checked, in order to ensure that it is not less than 50.  For the common side-effect of restless, aching legs, there is a drug called Baclofen.  Additionally, a seven night prescription of Zopiclone is also usually available, in order to help with sleep problems.

For specific withdrawal symptoms there are a range of medications to provide relief: loperamide (Imodium) is for diarrhoea; metaclopromide is for sickness; chlorphenamine (Piriton) is an anti-histamine for itching; Gaviscon is for stomach acid; senna or lactulose is for constipation; and of course, there are paracetamol and ibuprofen for general aches and discomfort.

It is both interesting and very sad to hear about the life problems that have caused patients to start abusing drink or drugs.  Common triggers can be bereavement, divorce, unemployment, or depression; there may be singular causes or there may be multiple and cumulative causes.  Whatever the reasons, it is interesting to note that substance misuse could potentially happen to anyone.  Patients should never be judged; they are nice, normal people who have often had to cope with some terrible problems, and they have made a brave and honest choice to undergo detox, to admit their drink or drug problems and to ask for our help.  I am proud to be involved in helping these patients, and I wish them all success and much happiness in the future.