Urinalysis

Urinalysis simply means analysis of urine. It is an easily performed investigation that can detect a wide variety of abnormalities within a few minutes at low cost. Urinalysis is an investigation which all nurses should be competent to perform and is identified by the NMC (2007) as being an example of an essential skill nurse students should be competent to perform before entering their branch programme. Urinalysis may be performed in a wide variety of clinical settings. It should be performed on every patient entering the acute care setting. Additionally, the National Confidential Enquiry into Patient Outcome and Death (NCEPOD (2009), stresses the need for urinalysis to be performed on all emergency admissions to an acute hospital. It may also be performed in outpatient and general practice clinics, and community areas. To obtain the most accurate information from the test, students need to know how to obtain and assess a sample of urine and be aware of factors that may influence the reliability of the investigation. Urine may be tested in three different ways. ● Macroscopic urinalysis, ● Microscopic urinalysis, ● Chemical analysis. Macroscopic and chemical analysis are the investigations performed in the clinical setting which may be tested by OSCE. Microscopic investigation requires samples to be sent to a laboratory. Macroscopic analysis is the analysis of the urine by the naked eye. Chemical analysis may be performed by use of a plastic diagnostic reagent strip or ‘dipstick’ which contains small pads of chemicals which react to substances that may be found in urine. For purposes of testing urine at random, clients are asked to urinate into a clean but not sterile dry container with no precautions regarding contamination. In females in particular this may result in samples being contaminated by vaginal fluids, such as blood or mucus. Due to the risk of contamination a mid-stream specimen of urine may be required if an abnormality is found in a random sample. A mid-stream specimen requires cleaning of the external urethral meatus prior to urination, passing the first half of the bladder contents into the lavatory, and passing the second part of the urine flow into a sterile container.

Measuring Blood Pressure

Blood pressure measurements are one part of a circulatory assessment (Docherty and McCallum 2009). Treatments for raised or low blood pressure may be initiated or altered according to blood pressure readings; therefore correct measurement and interpretation of blood pressure is an important nursing skill. Blood pressure should be determined using a standardized technique in order to avoid discrepancies in measurement (Torrance and Serginson 1996). Both manual and automated sphygmomanometers may be used to monitor blood pressure. The manual auscultatory method of taking blood pressure is considered the gold standard (MRHA 2006), as automated monitoring can give false readings (Coe and Houghton 2002), and automated devices produced by different manufacturers may not give consistent figures (MRHA 2006). So, although automated sphygmomanometers are in common use within health care settings in the UK, the skill of taking blood pressure measurement manually is still required by nurses. As a fundamental nursing skill, blood pressure measurement, using manual and automated sphygmomanometers, and interpretation of findings are often assessed via an OSCE. Within this chapter revision of key areas will allow you to prepare thoroughly for your OSCE, in terms of practical skill and understanding of the procedure of taking blood pressure. Blood pressure is defined as the force exerted by blood against the walls of the vessels in which it is contained (Docherty and McCallum 2009). A blood pressure measurement uses two figures—the systolic and diastolic readings. The systolic reading is always the higher figure and represents the maximum pressure of blood against the artery wall during ventricular contraction. The diastolic reading represents the minimum pressure of the blood against the wall of the artery between ventricular contractions (Doughetry and Lister 2008). You will need to be able to accurately identify systolic and diastolic measurements during your OSCE. When a blood pressure cuff is applied to the upper arm and inflated above the level of systolic blood pressure no sounds will be detected when listening to the brachial artery with a stethoscope. The cuff clamps off blood supply. As the cuff is deflated a noise, which is usually a tapping sound, will be heard as the pressure equals the systolic blood pressure —this is the first Korotkoff ’s sound.

Measuring, Assessing and Recording: Pulse, Body Temperature, Respirations and Oxygen Saturation

As part of the measuring physical observations simulated examination, students will be asked to measure, assess and record pulse, body temperature, respirations and oxygen saturation. This assessment is becoming more common in all universities as it has been identified as a mandatory simulated assessment within the NMC Essential Skills Clusters (NMC 2007). Although this chapter will focus upon each observation in turn, it is imperative that when undertaking physical observations the findings are not assessed in isolation. Like a jigsaw, each result, alongside the patient’s appearance, pallor, demeanour and responsiveness, link together to form an overall picture of the patient’s condition. The skill of undertaking these observations may sometimes be reviewed as being routine, but the skill has important clinical significance. Students have to demonstrate their underpinning knowledge and to make sense of the relevance of the observations—this can be complex and challenging. Some student nurses will have previous experience, prior to commencing their nurse education training, of taking patients’ physical observations, but the ability to demonstrate an understanding of the underpinning knowledge differentiates between the role of a health care support worker and a student nurse. Revision of key material will enable the student to understand, undertake and assess the relevance of measuring pulse, body temperature, respirations and oxygen saturation. The importance of the professional nurse’s ability to accurately assess, record and evaluate pulse rate, body temperature, respirations and oxygen saturation cannot be underestimated. Concern has been raised that NHS staff are failing to recognize patient deterioration in a timely manner. In a study by the National Patient Safety Agency (NPSA 2007) factors for this lack of recognition included failure to take physical observations, not acknowledging the significance of the observations and finally not reporting on issues that were of concern, or acting upon these findings. Guidelines on recognizing and managing patient deterioration have been issued by NICE (2007) alongside competencies for recognition and management of a deteriorating patient, which all staff working in acute settings should achieve (DOH 2009). Throughout these the importance of assessing, recording, evaluating and appropriately reacting to the results of physical observations cannot be denied.

Hand Hygiene and Infection Control

Each year hundreds of millions of people contract an infection while in the receipt of heath care. At any time 1.4 million people worldwide are suffering from an infectious complication associated with health care (WHO 2005). Health care acquired infections not only lead to pain discomfort, disability, and possible death for the recipient but also place a huge emotional and physical burden on relatives and carers. In England and Wales an average of one in 11,000 people die of a hospital acquired infection (HAI) each year; this figure rises to 1 in 300 for patients over the age of 80 (Bandolier 2006). Hospital admission is now a major risk factor for health care related infection (Gould 2009). In 2007 around 9,000 people in England died with an MRSA bloodstream infection or related Clostridium difficile infection (National Audit Office 2009). These figures do not include deaths from other HAIs so in fact the number of deaths from HAIs could be greater. In addition, it is also believed that many people die from a health care acquired infection which is not identified on the death certificate. In England, health care related infections have been estimated to cost a billion pounds annually (WHO 2005). The World Health Organization has identified hand hygiene as the primary measure to reduce infections (WHO 2009). Everyone involved in the provision of health care must be trained in effective hand decontamination (NICE 2003). Unclean hands move microorganisms from one place to another. Transmission of infection by hands has been identified with recent hospital outbreaks of MRSA and Clostridium difficile. Good hand hygiene is one of the most effective methods of reducing hospital acquired infections. Hand decontamination removes transient bacteria acquired from recent contact with an infected item or person. While hand decontamination is advocated before contact with every patient regardless of setting, patients in hospital are at greatest risk of acquiring an infection. In the UK 7.6% of patients admitted to hospital become infected. In England the figure is even higher at 8.19% (Nazarko 2008). It is essential for health care students to not only be able to perform effective hand washing, but also understand the principles of the procedure, as well as the possible physical, emotional and financial consequences of failing to perform hand hygiene.

Interpersonal Communication

Nursing is an interpersonal profession (Ellis and Whittington 1981) which is to say that the majority of the goals of the profession are met through the quality and nature of relationships the nurse is able to form. Effective interpersonal communication which underpins the therapeutic relationship is a complex set of skills which require the nurse to understand the context and purpose of the interactions, in addition to being aware of their own agendas and factors which might form a barrier to effective working relationships. Historically, interpersonal communication was implicit within nursing care and by the 1980s writers such as Morrison and Burnard (1991) and Porritt (1990) had identified and explored the nature of the therapeutic relationship and interpersonal skills within nursing care. Now authors such as Stein-Parbury (2009), Burnard and Gill (2008), Maben and Griffiths (2008), Freshwater (2005) and Greenhalgh and Heath (2005) have studied and written about this area in great depth. Both the Department of Health (DOH) (2010) and the Nursing and Midwifery Council (2008) have identified the centrality of patient-led care and the nurses’ ability to develop effective working relationships that enhance dignity and treat the person with compassion and care. A therapeutic relationship is significantly different from relationships that are formed socially amongst colleagues and friends. In order to establish a relationship which is helpful it is necessary to be aware of the assumptions, expectations and feelings you carry into each new professional relationship. Without this awareness there is a real danger that your own ‘noise’ will make it difficult for you to be present and experience the other person as they are. In order to understand the emotional needs and concerns of the person it is necessary for you to try to understand the world of the person that you are caring for—from that person’s own perspective. The nearer you can come to this the more effective will be the relationship, and the assessed needs of the patient will be more accurate and relevant. Learning about interpersonal communication within the context of nursing and the therapeutic relationship means that you will have the opportunity to develop your skills and adapt them for the purpose of caring for others.

Recognition of Acute Deterioration

Recognition and prompt treatment of the acutely ill patient is a significant issue in clinical practice (NICE 2007). The need for all nurses to be able to recognize, assess and promptly escalate (ensure timely and effective management) patients whose condition is deteriorating is stressed in the literature (NCEPOD 2005; NPSA 2007). Therefore it is an important skill and your university will want to ensure via OSCE that you are adequately prepared for any emergency that may arise in practice. It must be emphasized that this skill is a complex skill and most universities do not assess this skill until the final year of your course. The key to succeeding in this OSCE is understanding the need for systematic assessment, and timely intervention and escalation will be stressed throughout this chapter. It is likely that you will be allowed approximately half an hour to demonstrate this skill and answer related questions. Revision of key material will enable you to understand why assessment is important and provide you with a systematic framework to use in the OSCE and in clinical practice. Concern over NHS staff ’s management of the deteriorating patient has been highlighted in the literature since the late 1990s. McQuillan et al. (1998) first discussed the concept of suboptimal care suggesting that often deterioration in patients was ignored, misdiagnosed and/or poorly managed in ward environments resulting in increased mortality and morbidity in ward patients. Since McQuillan’s work several other studies have identified similar problems (McGloin et al. 1999; NCEPOD 2005). More recently NICE (2007) has published guidance on recognition and management of deterioration and the Department of Health (2009) has published competencies related to recognition and management of deterioration that all acute staff should achieve. Review of this literature highlights that several issues are clearly important in recognition of acute deterioration and the need to utilize a systematic assessment tool linked to a robust track and trigger scoring system is an important consideration in practice. Smith (2003) was instrumental in developing the ALERT® framework that has been adopted internationally as a robust systematic assessment tool.

Administration of Oral Medication

Medication administration is a key skill and it is vital that you are able to demonstrate safety in all aspects of the medication administration process in order to avoid harm or death to your patient. The NMC (2004, 2010) reiterates this point, highlighting that the administration of medicines is an important aspect of a nurse’s professional practice. They argue that it is not simply a mechanistic task, but one that requires thought, exercise and professional judgement. Studies suggest that medicine administration is one of the highest risk processes that a nurse will undertake in clinical practice (NPSA 2007b; Elliot and Lui 2010). Medication administration errors are one of the most common errors reported to the National Patient Safety Agency (NPSA). Indeed in a 12-month period in 2007, 72,482 medication errors were reported with 100 of these causing either death or severe harm to the patient (NPSA 2009). The frequency of these errors has led to a number of changes in the medication administration process. Alongside these important recommendations, most higher education establishments will want to ensure safety of medicine administration and may test this vital skill using an OSCE to ensure that you are adequately prepared for safe administration of medication in practice. There are a number of important laws and key documents that relate to the administration of medication and it is important that you understand these as they all impact upon your practice when administering medication to a patient. You may also be tested on your knowledge in relation to these areas so it is important that you have read these. Important documents you will need to know include: ● The laws that relate to medication in the UK, ● NMC Standards for Medicines Management (2010) (www.nmc-uk.org), ● Local policies related to hospital/Primary Care Trust (PCT) regulation of medication (refer to local guidance). There are a number of laws that influence the manufacturing, prescription, supply, storage and administration of medication. Whilst you will not need to study the intricacies of these laws you will need to understand the main issues each law covers.

Aseptic Non-Touch Technique (ANTT)

During the aseptic technique simulated examination students may be asked to demonstrate a clinical skill, usually a wound dressing, using an aseptic technique. This is becoming increasingly common in all universities as it has been identified as a mandatory simulated assessment in the essential skills clusters (NMC 2007). This skill is probably one of the most complex skills assessed during simulation and it is vital that students understand the principles of aseptic non-touch technique and are able to demonstrate application of these principles throughout the examination. Revision of this key material will enable the student to understand and apply the key principles of aseptic non-touch technique throughout the examination. This is defined as an infection acquired in hospital at least 72 hours after admission to hospital caused or precipitated whilst the patient is in hospital. Health care acquired infections (HAIs) have become a serious concern over recent years, costing the NHS an estimated £1 billion a year and contributing to some 5,000 deaths a year (Aziz 2009). One factor that has been identified as impacting on the increase in HAIs is the variation of techniques used in wound care. Two of the most common HAIs of recent times are MRSA (methicillin resistant Staphylococcus aureus) and C. Diff (Clostridium difficile). MRSA is a species of bacterium commonly found on the skin and/or in the noses of healthy people. Although it is usually harmless at these sites, it may occasionally get into the body (e.g. through breaks in the skin such as abrasions, cuts, wounds, surgical incisions or indwelling catheters) and cause infections. These infections may be mild (e.g. pimples or boils) or serious (e.g. infection of the bloodstream, bones or joints). C. Diff is a species of bacterium that causes diarrhoea and other intestinal disease when competing bacterium are wiped out by antibiotics. This bacterium can have major consequences for patients once contracted. However, a number of less profiled infections are contributing to the rise in HAIs e.g. urinary tract infection. Aspetic non-touch technique (ANTT) is the term given to carrying out procedures which require attention to minimizing the risk of cross contamination that could potentially lead to an infection.

Preparation for the OSCE Assessment

The need to prepare adequately for any university examination is beyond refute and students may struggle with the OSCE assessment if they are unprepared or have unrealistic expectations of the OSCE process (Bloomfield et al. 2010). Adequate preparation will enable you to: ● Minimize any anxiety related to the examination, ● Understand the requirements of the OSCE, ● Facilitate accurate, systematic and timely performance of the OSCE, ● Enable you to give full justice to your professional ability…. OSCEs represent an important opportunity for you to further develop your nursing knowledge and skills. Effective preparation will give you a better opportunity to learn effectively from your OSCE and enable you to view the experience positively (see Chapter 14 Reflecting upon your OSCE). Preparation for your OSCE will clearly be affected by your own learning style and where and how you study is likely to be adapted to suit your own learning needs. You may well have completed a learning style assessment quiz such as Honey and Mumford’s (1986) at university; if not, you are able to access this online. It may be best to link your study for your OSCE to your learning style. Honey and Mumford (1986) identified several differing learning styles that are briefly described here. These include: ● Reflector: Tend to explore issues in depth before reaching a decision, ● Theorist: Logical and enjoy researching and using theory to enable understanding, ● Pragmatist: Like to apply things in practice and experiment with new ideas, ● Activists: Are open to new ideas and learn through experience alongside others. Therefore you can use your understanding of your learning style to help plan how you may best revise/prepare for your OSCE. For example: ● Activist: May prepare best by practising for your OSCE with your colleagues and practising your OSCE in the skills room or in a group outside of university. ● Reflector: May learn best by reviewing your own experience or learning from reflecting on experiences you have had in clinical practice. ● Theorist: May prepare by reviewing the literature and reading around the subject matter of your OSCE in appropriate literature, OSCE and clinical skills books.

Reflecting Upon Your OSCE

Once you have completed your OSCE assessment you will be informed of the outcome of the assessment. This may be on the day, if it is a formative assessment, or sometime afterwards, if it is a summative examination that has to be processed through an examination board. You should be provided with detailed written feedback about your performance at the OSCE and it is useful to review this alongside your recollections of the experience as this will help you to learn from the experience. Reflection is an important tool to use whether you have been successful or unsuccessful during your OSCE. It is important in nursing that we are able to reflect and learn from both positive and negative experiences. Some universities may require you to reflect on your OSCE as part of the examination. Again this may be on the day, immediately after your OSCE or a short period afterwards by reviewing a video of your OSCE (the latter normally happening as part of a formative learning process). Reflection is not unique to nurses and is something that we do throughout our lives. In everyday terms reflection may be described as an examination of our personal thoughts and actions (Somerville and Keeling 2004). In nursing you will be encouraged to develop reflective skills to facilitate your learning in the university and in practice this is often referred to as reflective practice and is slightly different to ‘everyday reflection’. Indeed throughout your nursing career you will be encouraged to develop reflective practice skills and become a reflective practitioner. Reflection as a process was first discussed in 1933 by John Dewey who first identified the need to evaluate our experiences and learn from them. In nursing as with most concepts there are a number of definitions of reflection and this can at first appear to be confusing. Simplistically reflection can be defined as a process of examining and exploring an issue that is related to an experience that results in new learning. Therefore reflection refers to a series of steps that you may take to question and explore an experience with the aim of learning from it (Hart 2010).