An audit of problems associated with urinary catheter withdrawal

Long-term catheterisation is associated with many complications, including urinary tract infections which may lead to encrustation and catheter blockage. Current management of catheters susceptible to frequent blocking is to attempt to prolong catheter life by using bladder maintenance solutions or to change catheters proactively by identifying a characteristic blocking pattern for the patient. However, catheter removal is associated with a number of problems. This article describes an audit conducted in one trust to identify the types of catheter material associated with removal difficulties. All-silicone catheters appeared to have a higher incidence of reported problems. The formation of a 'cuff' in all-silicone catheters when the catheter balloon fails to deflate to its original shape has been investigated as an important factor in difficult removal. The audit also examined what action was taken when nurses were unable to remove a catheter.

Use of gloves in the community: why, when, which and how?

The use of gloves has become routine since the early 1980s. It is recognized that they have an important part to play in the protection of both staff and patient/clients in the prevention of cross-infection. However, as choices relating to glove usage have increased over the years, health-care staff need to adopt a risk assessment approach, considering why, when, which and how gloves should be used. This article outlines the different types of gloves available and when they should be used.

An abdominal wall simulator for testing suprapubic urinary catheters

Urinary catheters (drainage tubes) are in widespread use. The most common type of long-term catheter is the Foley, which is made from natural or synthetic rubber. Foley catheters are passed into the bladder via the urethra or the suprapubic puncture channel (through the abdominal wall). A simulator for the abdominal wall has been developed to simulate aspects of the interaction between it and a suprapubic catheter. The simulator is based on a slab of ultrasoft elastomer with tensionable reinforcing polyamide filaments. The behaviour of the simulator has been compared with data published. A soft membrane (contact pressure) transducer (SMT) was used and novel instrumented 'tongs' for lateral indentation of the puncture track giving indentation stiffness. Slab materials were used with shear moduli of 0.1 and 0.021 MPa. Two filament-tensioning methods were used: by clamping to a winding mechanism and by weights. The combination of the softer slab material and tensioning by weights gave good conformity to physiological data; other combinations did not.

Providing seamless community health and social services

This article reviews a variety of Government community health policies and initiatives, from the NHS and Community Care Act 1990 to the emergence of primary care groups (PGCs). The Labour administration abolished GP fundholding and has placed considerable emphasis on its commitment to partnership with the care professions. The Government is also expecting a commitment to partnership between the community care professions in order to reflect the entwined social and health-care needs of the individual requiring care in the community. The role of the district nursing service has been brought into focus with the opportunity of representation at PCG board level. Evaluating how a district nursing service may integrate with social services is therefore, and appropriate strategy for assessing whether recent policy initiatives go far enough at grass roots level in facilitating collaboration and quality community care.

Nursing inputs to special schools in N. Ireland

Children attending special schools often have healthcare needs that require ongoing medical and nursing care. Two postal surveys were undertaken of 47 special schools in N. Ireland to determine the type of contact they had with nurses and the functions they fulfilled. Responses were received from 42 school principals and from the 11 Health and Social Service Trusts responsible for nursing services. It was found that nurses were based in nine of 42 schools while the remaining schools depended on a range of different visiting nurses. The nurses were involved in 'hands-on' tasks as well as giving advice and training to school personnel. Further research needs to define more closely the nursing needs of these pupils as well as evaluating the differential benefits of various nursing services to schools and how their inputs can be coordinated with those of other health professionals.

Optimization of debris removal during bladder irrigation

Debris build-up within the bladder is one of the main problems encountered by patients undergoing long term catheterization. One of the methods of ameliorating this is to wash out the bladder at regular intervals. In this paper, an alternative method of bladder irrigation is investigated experimentally. The effectiveness of several possible catheter designs has been examined, together with other relevant variables such as the proximity and alignment of the tube tip to the debris and the irrigation flow rate. Results show that debris removal is very sensitive to tube design, with best designs achieving almost complete removal and the worst practically none. The proprietary continuous irrigation catheter used was particularly poor for the type of debris used. Removal is insensitive to the distance of the tube tip from the bladder base up to a limiting value, above which it reduces rapidly. Where misalignment causes the inlet jet to miss the debris, removal rates are very low. Increasing flow rate increases removal up to a limiting value, above which it remains constant. Although the results show the general trends, to optimize the system requires further understanding of the detailed flow patterns within the bladder. A theoretical study using computational fluid dynamics is thus being undertaken.

Asthma care by nurse practitioners in the United States

PURPOSE

To survey nurse practitioners (NPs) in the United States on their level of input to asthma care prior to enrolling in The National Asthma and Respiratory Training Centre (NARTC) specialist asthma education program in the UK.

DATA SOURCES

Responses of 134 (66%) of the 202 NPs who self-selected for enrollment in the NARTC program on a preliminary questionnaire.

CONCLUSIONS

Nearly all (133 or 99%) currently work with asthmatics and 122 (91%) prescribe asthma drugs. Only 92 (69%) measure peak flow(PF), 84 (63%) check inhaler technique, 76 (57%) teach use of a home PF meter and diary, and 63 (47%) provide written self-management plans on any regular basis. Many have not established follow-up procedures (56 or 42%), or evaluated their asthma management practices (55 or 41%).

IMPLICATIONS FOR PRACTICE

Successful asthma management requires correct medication, systematic follow-up, patient education, and self-management. Specialist asthma training should encourage practitioners to combine effective drug usage with a long-term preventative approach.

Breakthrough pain: assessment and management in cancer patients

This article provides an overview of breakthrough pain in cancer patients, what causes it, current treatment options and the impact it has on individuals. It considers the importance of accurate assessment, the use of assessment tools and the growing role of nurses in managing this challenging pain syndrome. The article aims to open the debate on the need for new choices in pain management. While many advances have been made in the treatment of pain, there is still room for improvement in both the pharmaceutical and general management of the condition. Suggestions are made as to how these may be met.

Compression hosiery in venous insufficiency: a natural nurse-led field

The use of compression hosiery for the treatment and prevention of venous ulceration caused by venous insufficiency is commonplace in community practice. In recent years the role of the nurse in the management of these patients has grown supported by increasing levels of knowledge, nurse specialists and the implementation of nurse prescribing. The full list of compression hosiery items available on NHS prescription are included in the list of nurse prescribing items in the Nurse Prescribers' Formulary and the Drug Tariff. Central to a successful treatment outcome is the patient assessment. This forms the base of a partnership approach to care upon which product choices and advice can be tailored to meet the individual needs of that patient. An understanding of venous physiology, limb measurement skills and hosiery care place the nurse in an ideal position to lead in this area of nursing practice.

Use of the Polaroid Macro 3 SLR camera in wound assessment

Patient assessment is essential to effective care and facilitates systematic care planning. Assessment must be performed in combination with good documentation and accurate record keeping. Clinical governance, risk management and accountable practice are continuously emphasized by the UKCC (1992, 1998) and Department of Health (1998), and in the light of increasing litigation, it is imperative that planned and given care is accurately documented.

The benefits of integrated nursing teams in primary care

This article reports a study in which a literature search, questionnaire study and interviews were used to measure the costs and benefits to patients and professionals when nurses work in integrated nursing teams in primary care. Our study showed that there are significant benefits for the nurses' employers, the primary health-care team, the nurses and the patients. Compared with traditional models, delivery by integrated nursing teams can offer a much higher quality service. Patients can expect to be cared for by a team in which morale is high, communication is good and care is efficient and effective. The team can also offer many specialist services that were not previously available. Integrated nursing teams are most effective when the management savings are used by the teams to meet their professional and client needs. Financial savings, therefore, cannot be expected. The difficulties that arise when such teams are set up should be short-term and surmountable, but will be influenced by the motivation of the team members and the efficiency of the human resource management.

Transfix: a new range of all-silicone male incontinence sheaths

Urinary incontinence can have a significant detrimental effect on a person's body image and self-esteem because it undermine society's norms relating to control of the body. This can be further complicated by the use of devices to control urinary incontinence. Sheath drainage systems are the most common method of managing urinary incontinence in men. A discreet, reliable sheath drainage system can have both physical and psychological benefits. A full continence assessment is paramount for a successful outcome as there are several potential problems associated with this method of management. There are many products available, so the health professional needs a comprehensive knowledge of both products and application techniques. The Sims Portex Transfix range of all-silicone self-adhesive sheathes have many benefits and offer a reliable form of sheath management for male urinary incontinence.

The value of community mental health nurses based in primary care teams: 'switching the light on in a cellar'

This paper explores the impact of placing Community Mental Health Nurses (CMHNs) at two primary care practices in South Staffordshire. Data were collected by means of a questionnaire which was sent to primary care personnel at these practices, to ascertain their opinions with respect to the contribution of practice-based CMHNs. Overall, primary care personnel were satisfied with the quality of the service received from the CMHNs, especially in terms of improved communication. They felt that the new arrangements enabled a quicker and more efficient access to the services of the CMHN. The results are discussed in terms of the value of having CMHNs within the primary care setting, and in terms of service planning and future recommendations for mental health services within primary care.

Health education, behavioural change and social psychology: nursing's contribution to health promotion?

AIMS

To critically review the complex processes that underpin the modification of a client's health-related behaviour. This paper also seeks to contextualize the operational differences between health-educating and health-promoting activities - as a means of rationalizing current practice.

BACKGROUND

In "health promotional" encounters, there is a plethora of evidence that suggests that nurses work predominantly within a "traditional" preventative framework of practice. The prevalence of a culturally inherent biomedical framework, governing most nursing practice, tends to reduce health-related client interventions to little more than one-off, reductionist information-giving exercises. The expectation on clients to respond to and subsequently modify their health behaviour, when presented with such information, is unrealistic in most cases. Nurses are often unaware of the extremely complex human phenomena associated with modifying health-related behaviours and the resultant change processes. In nursing-related health encounters, the planned or unplanned intervention and the subsequent outcomes are mostly viewed within a too simplistic and superficial context.

DESIGN

A selective review of the relevant literature.

CONCLUSION

Where many nurses believe themselves to be health promotionalists, the likelihood is that they are instead more likely to be traditional health educationalists. Not that this is the main problem, in itself--but if nursing is to progress on this issue, it must first become more effective in delivering its current health education initiatives. Armed with further knowledge and understanding of their practices, health educators are far more likely to achieve a degree of success in their behavioural-change encounters as well as approach the intervention with a far more realistic expectation of outcome. Without this further understanding, it is argued that the integration of health educational initiatives into nursing practice will generally do little or nothing to change the health status of clients.

Restoring pleasure: nutritional management of dysphagia

Dysphagia is associated with many different conditions and although widespread it is frequently not recognized. People with dysphagia are at risk of developing serious complications such at malnutrition, dehydration and aspiration. Texture modification, food fortification and dietary supplements are important elements in effective nutritional management of dysphagia and can also help bring back some of the pleasure to mealtimes. The ideal approach to the management of dysphagia involves a multidisciplinary team.

Why catheterize?: audit findings on the use of urinary catheters

Urinary catheters can be associated with complications such as urinary tract infection, pain and discomfort. This article reports on an audit of 51 patients who had a urinary catheter inserted during their hospital stay. Urinary incontinence meant catheterization in 37.5% (n = 27) of cases, with 64.7% (n = 33) being catheterized by nurses. The study highlighted the need for accurate documentation and care planning; 15 patients did not have a plan of care for their catheter and only eight patients had a plan for the removal of the catheter. Catheterization is the most common cause of hospital-acquired infection, and therefore the use of catheters needs careful examination to reduce this type of infection. The question is raised whether catheterization is used as a convenience for nursing staff or as an essential aspect of care.

Nutrition and the life cycle 5: nutritional needs of older adults

The previous four articles in this series on nutrition and the life cycle reviewed the nutritional needs during pregnancy (Vol 9(17): 1133-8), infancy (Vol 9(21): 2205-16), childhood (Vol 10(1): 26-31) and adulthood (Vol 10(6): 362-9). This article, the last in the series, will review the special nutritional needs of the older person. Older adults form an increasing proportion of our society, and it is important that nurses appreciate their special needs. The article concentrates on the health older adult, and reviews what nutritional advice nurses should be providing order to help them achieve maximal health.

The need for palliative care for patients with non-cancer diseases: a review of the evidence

The palliative care needs of patients with cancer are understood and managed well by specialist palliative care services. Patients dying of non-cancer diseases are rarely offered these services. A literature review was conducted to determine the physical and psychosocial problems of patients dying from non-cancer diseases. Studies were identified using a systematic keyword search of six electronic databases. Fourteen studies were identified and assessed according to rigour of design. Findings suggest that some patients dying of non-cancer have needs comparable with those dying of cancer. Low response rates, subject bias, and measurement bias mean that findings should be viewed with caution. More prospective, rigorously designed research is necessary to identify which patients with non-cancer diagnoses may benefit from specialist palliative care.

A policy analysis of the Expert Patient in the United Kingdom: self-care as an expression of pastoral power?

The rise in chronic illness and comorbidity in Western society has resulted in an increasing emphasis on self-care initiatives. In the United Kingdom this is exemplified by the Expert Patient policy. This paper discusses the Expert Patient initiative as an example of the State's third way approach to public health. The extent to which this policy challenges conventional power relationships between professional and patient, and fosters equal partnership is examined. In particular, how expert is defined and whether a professional understanding of the term is reconcilable with a patient's expertise is debated. The paper argues that the Expert Patient initiative is unlikely to reconstruct chronic illness and may further complicate the State's responsibility in meeting the needs of those with chronic illness. Issues of power within self-care are explored to illuminate the policy, and this paper argues that the Expert Patient initiative is an example of Foucault's notion of pastoral power. Although the Expert Patient policy focuses on the rights and responsibilities of those with chronic illness, this paper concludes that there is no corresponding strategy to challenge professionals' assumptions toward those with chronic illness.

The case for researching the history of community nursing practice

Despite a flurry of interest in the 1980s, the adoption of a positivist, objective, scientific paradigm for nursing research has led to a rejection of the study of nursing history as a valid pursuit in recent years. In this article, it is argued that this is a precarious situation. By not examining the history of the profession, nursing -- and in particular community nursing -- undermines its efforts to validate itself within the wider health-care arena. Nursing must learn from the mistakes of the past, as well as the successes, but do so in a critical way that does not romanticize its history.

Community nurses', home carers' and patients' perceptions of factors affecting venous leg ulcer recurrence and management of services

AIM

This study examines the feasibility of utilizing social service home carers (SSHC) to provide a collaborative approach with community nurses for the provision of leg ulcer aftercare in four National Health Service (NHS) Trusts. The purpose of this study was to gain insight into what community nurses and people with healed venous leg ulcers felt influenced leg ulcer recurrence.

BACKGROUND

Studies have demonstrated that provision of community-based leg ulcer clinics has improved healing rates of venous leg ulcers, yet recurrence remains a problem. The reasons for this are far from clear, and further research is required before unequivocal support can be given to one approach to the provision of care for this client group. Collaborative approaches to the provision of leg ulcer aftercare are beginning to receive more attention. It has been recognized that social service health carers could be co-opted to provide essential aftercare once healing has occurred, although the logistics of this approach have not been fully explored.

METHODS

This study was conducted in four NHS Trusts. Stage one used focus groups to explore the perceptions of district nurses (n = 15) and social service health carers (n = 15) of a leg ulcer shared care project and to gain insight into factors that they felt influenced recurrence. The second stage used semistructured interviews (n = 12) to explore the perceptions that people with healed leg ulcers have about factors influencing ulcer recurrence.

FINDINGS

Key themes emerging from this study were: health promotion is perceived by community nurses and patients to be ineffective and leg ulcer aftercare services are fragmented. Organizational factors such as time constraints and limited resources were cited by community nurses and home carers as being responsible for high leg ulcer recurrence rates. Community nurses expressed a desire to delegate preventative aspects of leg ulcer care to home carers rather than participate in health promotion strategies to support healing behaviours.

CONCLUSIONS

A strategy aimed at supporting healing behaviour in elderly people has the potential to reduce the recurrence of leg ulceration and improve quality of life. The findings suggest that such a strategy needs to rationalize delivery of leg ulcer aftercare to provide seamless care. It needs to improve carers' and patients' understanding of factors influencing leg ulcer recurrence and facilitate development of a more balanced professional--patient relationship.

Improving the health of older people: what do we do?

This article, based on a paper given at the International Network for Studies Concerning Older Adults conference in Brazil, considers the health of older people. It argues that greater efforts must be made both to improve preventive healthcare interventions and enhance quality of life. It is suggested that nurses have a significant but, as yet, largely unrealized role to play and that action is needed if older people are to get maximum benefit from health care.

Record keeping and nurse prescribing: an issue of concern?

As options are explored by the NHS Executive to extend nurse prescribing in terms of expanding the Nurse Prescribers' Formulary and widening the groups of nurses eligible to train to prescribe, issues surrounding record keeping in the community need to be revisited in order to safeguard professional integrity. Prescribing nurses in the community face barriers to accurate and adequate record keeping when access to all patients' records is not permitted and/or time constraints and extra travelling impede the process, potentially threatening the safety of the patient. Until information technology provides the answer to safe and effective use of shared patient records, nurses who prescribe any treatments need to ensure they share full access to all patients' notes.

The practice nurse's role in the management of epilepsy

Epilepsy is a serious and common neurological condition of which the medical, psychological and social implications are far-reaching. This article aims to discuss the practice nurse's role in responding to the needs of clients with epilepsy. This is explored from a primary health care perspective, focusing on nursing interventions and implications for practice. The potential exists for community nursing intervention to improve quality of life for clients through responsive service provision and by challenging the inequality that appears to exist with regard to it. The available research is overtly pharmacological in origin and nursing research in this field is extremely sparse.

Head lice: changing the expensive chemotherapy culture

The revulsion prompted by the discovery of head lice on a child's head, and the money spent by the NHS each year on supplying licensed medicines for head lice, is disproportionate to the medical impact that lice have on their hosts. This article discusses the evidence available on the effectiveness of the commonest parasiticidal preparations, and argues the case for a more rational, simpler and cost-effective response to this common problem.

The management of constipation in people with advanced cancer

Constipation represents a significant problem for people with advanced cancer. It ranks in the top three most uncomfortable symptoms experienced, causing pain and anorexia that ultimately result in misery. The negative impact upon the quality of life of the patient and their carers is significant. The key to the provision of effective care lies in the informed application of the nursing process, underpinned by a sound knowledge base in relation to the management of constipation. Theoretical knowledge enables appropriate preventative interventions to be planned in collaboration with other members of the multidisciplinary team. When preventative measures are not applied or are unsuccessful, informed assessment and care planning enables appropriate interventions to be applied in order to resolve constipation. This article will discuss the causes and management of constipation. The discussion focuses on assessment, setting goals with the patient and their carers, planning appropriate nursing interventions to support medical interventions and evaluating clinical outcomes.

Nurses' use of computer databases to identify evidence for practice--a cross-sectional questionnaire survey in a UK hospital

The objectives of this study were to determine nurses' use of electronic databases to inform practice. A questionnaire survey of 114 nurses working on five acute wards in a large inner city teaching hospital investigated their general use of computers and the three databases, CINAHL, MEDLINE and the Cochrane Library. Eighty-two qualified nurses responded (response rate 72%). The results show limited confidence and low frequency in using the databases. Thirty-four per cent expressed low confidence using CINAHL. Twenty-seven per cent used CINAHL on a regular basis. Twenty-two per cent never used it. Eighteen per cent were unaware that it was available locally. Knowledge and use of MEDLINE was even lower with only 18% using it regularly. Knowledge of the Cochrane Library was extremely limited, with 75% unaware of its existence. Use of a home computer and higher education were associated with higher frequency of use of CINAHL and MEDLINE. If nurses are to make use of electronic resources to contribute to evidence-based practice, effort needs to be put into ensuring that already qualified nurses have basic computer skills and specific knowledge of available resources. More emphasis should be placed on 'evidence-based' resources, such as the Cochrane library, as sources of information for practice.

District nurses and home carers 3: project evaluation

This article, the last in a series of three, discusses the evaluation of a project established to provide a programme of education for social services' home carers that focused on the development of skills relating to care work. This education was delivered by district nurses (DNs) to address a number of problems associated with the provision of personal care identified by the home carers and their DN colleagues. An action research framework was used to improve collaborative working between the staff of the two disciplines. The article outlines some of the key findings from the evaluation of the project in relation to the structure, the process and the outcome of the project. The project evaluation was mainly positive and this success can be partly attributed to the fact that an action research method was used to drive the project.

Family support by lay workers: a health visiting initiative

There has been considerable research on the effectiveness of intensive professional home visiting schemes in improving parenting; lay visiting schemes, however, although often popular with clients, are under-researched. This article focuses on a lay visiting scheme set up and supported by health visitors in a deprived inner city area of Sheffield between 1998 and 2000. Although this scheme was designed to run for 2 years, an interim evaluation has taken place to track its effectiveness. This mainly qualitative evaluation has not only shown benefits to clients but also identified a number of issues for safe practice. The scheme has now been awarded core funding. It illuminates the kind of relationships that can develop between lay workers and clients, and enables a discussion of the benefits of this project and the challenge such schemes can present to both policy and practice.

The use of metaphor in district nursing: maintaining a balance

AIM OF THE STUDY

To explore with practitioners and others, their priorities for and definitions of district nursing.

BACKGROUND/RATIONALE

This paper discusses whether the use of metaphor in nursing literature and research can offer particular insights about the situation and experiences of nurses.

DESIGN/METHODS

A case study approach was used to examine district nursing during a time of policy change. The study was undertaken in two stages using a range of qualitative methods of enquiry. Participants of the study were district nurses, General Practitioners (GP) and Community Nursing managers.

RESULTS/FINDINGS

Qualitative data from interviews and periods of observation revealed that district nurses, and to a lesser extent General Practitioners and nurse managers used a shared group of metaphors to try and capture district nursing work. The paper suggest that this recurring group of metaphors demonstrated coherence between the language used, observed practice and accounts of how district nurses worked which provided useful insights for district nursing. The metaphoric language revealed both negative and positive dimensions of district nursing work. It illuminated the context dependent nature of district nursing work and the conflicting interests they had to accommodate. It also revealed the emotional work, skills and strategies district nurses employed in order to achieve their work.

CONCLUSIONS

The paper concludes that an examination of metaphoric language offers an opportunity to examine what otherwise would be tacit or even misunderstood in nursing work.

Evaluation of an electric bed frame and pressure-reducing mattresses

Pressure ulcers remain a challenge to all healthcare professionals. With the trend towards caring for ill patients in the community there is a need to ensure that equipment used to prevent pressure ulcers in these patients is effective. It is not always appropriate to simply use equipment designed for hospital. This article describes the evaluation of an electric bed frame and three mattresses specifically designed for patients in the community, in either their own homes or nursing home/residential care. The location of this research can reduce the number of participants recruited. In order to compensate for this, three different methods of evaluation were employed - clinical, laboratory and anecdotal - which have produced results relevant to both purchasers and users of the system tested.

The role of community-based nurses in health promotion

It is the responsibility of all nurses to incorporate health promotional and health education activities into their professional roles. Much of the literature around this issue relates to the specific role of community-based nurses in the primary healthcare team, and identifies their unique position and responsibility for pioneering the universal acceptance and adoption of health-promoting practice. Community-based nurses are in a good position to commission health-related activities and integrate them into practice (Department of Health and Social Security, 1987; Department of Health, 1992, 1996). On the basis of this, one might expect that the results of studies in this area would identify evidence of good understanding, adoption, parity and support for such initiative among community professionals. However, many studies have identified a state of confusion, poor understanding, a lack of parity between professional groups, a lack of professional support and training, and haphazard implementation of such strategies (Dines, 1994; Russell, 1997). Inconsistency in study findings is problematic and tends to present a skewed picture of current practice. It is suggested that community-based nurses may benefit from a change in the way they view the implementation of health promotional practices, and that policy issues related to practice could be further clarified and enforced.

Quality of life in leg ulcer assessment: patients' coping mechanisms

An increase in autonomous practice and the need to evidence professional update puts demands on individual nurses to reflect on their knowledge and practice. Community nurses have become expert at managing wounds, particularly leg ulcers, and using a variety of assessment strategies. However, reflections focused on the expert patient and their coping mechanisms may suggest that holistic assessment and treatment of these patients requires consideration of additional factors. The introduction of quality of life (QoL) tools may provide the rationale for an individual patient's nursing care in this specific context. Placing emphasis on the social and psychological impact of living with a leg ulcer - from the patient's perspective - may direct collaborative assessment and informed decision making.

Managing people on sip feeds in the community

Community nurses often have the difficult task of identifying and coordinating the care of under-nourished patients in the community. Studies have shown that patients who are underweight are likely to visit to their general practitioner more often, need more medication and be admitted to hospital. Nutritional sip feeds have been shown to clinically benefit underweight patients suffering from chronic conditions as well as the older people. Adapting ordinary food to meet the patient's nutritional requirements should be considered first, but sip feeds provide an additional source of nutrients when this proves insufficient. All patients on sip feeds should have a clear aim for this nutritional intervention (e.g. the healing of a pressure area) and be monitored regularly.

Recording wounds: Polaroid's new medically-designed cameras

Wound management is an important and increasingly complex area of nursing practice. Community nurses, in particular, spend a considerable amount of time assessing, evaluating and managing chronic, non-healing wounds. The rapid rise in the number of wound care products, combined with the emphasis on clinical governance and risk management, and increases in litigation have meant that accurate documentation and record keeping have become an essential part of care (UKCC, 1992, 1998). A standardized approach to assessment, classification, measurement and evaluation should be adopted to maximize optimal patient outcomes. There are a number of techniques for measuring wounds, ranging from manual measurement using tracing to computer-based imaging. Photography is a simple and quick form of documentation, which provides an accurate and objective record of the wound. This article highlights the benefits of using the new Polaroid Macro 5 SLR camera in wound documentation.

Reality bites on Big Brother

Unlikely as it may have seemed at the beginning, Big Brother ended by highlighting the uncomfortable reality that is healthcare rationing in the UK. Dismissed by the more cynical among us as a game-winning ploy, Craig’s donation of his prize money to provide a heart-and-lung transplant in the US for his best friend’s cousin with Down’s syndrome turned out to be genuine.

Schizophrenia: management and care in the community

The move to community care has resulted in many more individuals with severe mental health needs relying on community services. Community facilities did not receive the proceeds from hospital closures and this had led to inadequate provision and facilities for individuals with severe mental health needs. There also appears to have been a lack of effective interventions and skills for dealing with this specific client group. The National Framework Strategy (Department of Health, 1999) for mental health outlines ways to modernize mental health services and aims to ensure that they will be more accessible, more effective and coordinated across health and social care. Over the past decade, there has been a great deal of research examining the effectiveness of psychosocial and family interventions for individuals with psychosis. This article discusses how such interventions could address some of the shortcomings of community care for the severely mentally ill.

Nurses' views about pain and trauma at dressing changes: results of a national survey

Research findings and professional concerns that patients still experience pain and tissue trauma at dressing changes led specialist nurses to develop a postal questionnaire to elicit the views of 1000 nurses with an interest in wound management. The questionnaire asked practitioners to identify the primary considerations underpinning their approach to pain and tissue trauma at dressing changes, the strategies they adopted, and the factors which determined their treatment choices. The higher than anticipated response rate (37%) illustrates the importance nurses attach to this aspect of practice. The practitioners' main considerations during dressing changes were the need to prevent trauma to the wound (47%) and to avoid causing the patient pain (34%). Significantly, 81% noticed that patients experienced most pain when dressing products were removed, highlighting the need to re-emphasise the principles of moist wound healing. A total of 225 respondents (60%) were aware of dressings specifically designed to prevent pain and trauma during dressing changes. Practitioners also had the freedom to use the product of choice all (61%) or most (36%) of the time. However, respondents also demonstrated confusion about the properties and availability of many dressings. Recommendations for practice include reviewing the number of dressings currently available, together with ongoing education and update on all wound management dressing products and related issues.

Management of the older person with diabetes in the community

As the incidence of diabetes increases in the UK, community nurses will have increasingly larger caseloads of elderly patients with diabetes. It is important that nurses assess the patient's understanding of the disease and its treatment. The aim of good diabetic control is to reduce morbidity from the complications of the disease. Factors that affect the patients' quality of life; the patients' ability to manage their condition; and the importance of providing education and support for both the patients and their carers are discussed. The importance of diet, blood glucose monitoring and taking diabetic medication appropriately are explained.

Crown II: the implications of nurse prescribing for practice nursing

Certain limited prescribing rights have now been granted to district nurses and health visitors. Proposals to extend prescribing rights to other health professionals have recently been put forward in the Review of Prescribing. Supply and Administration of Medicines (DoH, 1999). Practice nurses are one group who are likely to apply for such rights. This article reports on selected findings from a small-scale qualitative study designed to investigate the current and potential future of practice nurse in prescribing. It was found that practice nurses exercise considerable influence over prescribing in diverse therapeutic areas within general practice. However, it may be difficult to accommodate the prescribing requirements inherent in such a broad scope of practice within the framework of the present proposals. Important issues of accountability and patient safety are raised, and recommendations made for policy, research and education.

A study of district nurses' experiences of continuous ambulatory chemotherapy

As a result of technical developments and policies that promote shorter hospital stays, patients are increasingly receiving high technology treatment in the community. The administration of ambulatory intravenous chemotherapy at home is an example of such treatment. Despite being generalist nurses, district nurses (DNs) are involved in what could be viewed as 'specialist' care - advising and supporting patients while they are receiving treatment. This article reports on a study of 20 DNs from one community trust and examines the sources of the knowledge and skills used in caring for these patients and the communication links with the regional cancer centre.

'Naturalistic vs reductionistic approaches to health-related practice: opposing dichotomy or symbiotic partnership?'

Complementary therapies, within Health Service arenas, have traditionally been associated with 'naturalistic' approaches to health care provision rather than with 'reductionist' practices. Evidence does exist, however, that certain approaches to complementary therapies can exist comfortably within both camps. Subsequent debates within nursing literature, surrounding the place and validity of reductionist approaches to health care provision and their relationship with the 'counter-part' naturalistic (i.e. empowerment) approaches to health care, have existed for some time now. Naturalistic (inductive and interpretive) and reductionistic (deductive and fixed) classifications of health care provision have continued to be viewed, by many health care professionals, as apposite, divided and allopathic. This appears to be even more so recently where elements of reductionist health care have been portrayed in terms that serve to undervalue and undermine its contribution. This is whilst naturalistic approaches, in far more favourable terms, have gone on to be 'championed' by many health professions. This account sets out to investigate how this situation impacts upon the discipline of complementary therapies. It seeks to do so by defining the nature and purpose of these differing approaches - particularly within the boundaries of health promotion activities. It goes on to suggest that our current practices/viewpoints, related to these particular approaches, could be considered in themselves to be flawed, limiting and reductionist with a potential to unwittingly create a counterproductive practice ethic. As an alternative to this situation, it is suggested that by identifying the strengths and weaknesses of both stances it is possible to find common ground which marries together the more favourable aspects of these approaches. This can subsequently provide a clearer and more productive consensus for complementary therapies and other naturalistic-based practices to move forward.

Palliative care in the community: the challenge for district nurses

Palliative care is expanding out of the hospice, and out of the narrow confines of its association with cancer. It should be a part of all care. District nurses are ideally placed to implement and coordinate palliative care in the community, making use of the talents of many other agencies and professionals. However, because of a lack of communication between these agencies, there is confusion about their roles, and many patients may not be receiving optimal care. This article argues that by promoting interagency and interprofessional communication and cooperation, district nurses can strengthen their role at the heart of palliative care provision in the community.

Bladder washouts in the management of long-term catheters

It has been estimated that 40-50% of patients with long-term catheters can suffer with catheter blockage. This not only causes distress to the patient but also increases the demands on community nurses' time and resources. Infection with bacteria such as Proteus causes the urine to become alkaline. Crystalline deposits can then form inside the catheter lumen which causes blockage. Nurses often manage blocked catheters with the use of bladder 'washouts' or bladder instillations. However, the literature is confused over the terminology of 'bladder washouts', instillations and irrigation and a great deal of controversy surrounds the effectiveness of these procedures. Crisis management of catheters occurs when nurses wait for catheters to become blocked before changing them; this often occurs at inconvenient times and patients frequently have to wait several hours before help is available. To avoid crisis management, nurses should aim to assess individual patients' 'pattern of catheter life' and plan changes accordingly. This would improve patient care and allow nurses to utilize their time more effectively.

Health promotion in leg ulcer management in the community

This article acknowledges the substantial progress that has been made in leg ulcer management in recent years. However, there needs to be greater emphasis on health promotion, quality of life, general patient well being and promoting health within illness. Incorporating health promotion activities within venous leg ulcer management strategies may serve to empower patients to participate more fully in their care. Nurses' awareness needs to be raised to ensure that the assessment process is used as a tool to promote holistic care and not merely as a checklist to provide baseline information on the patient's health status. A series of factors highlighted during assessment are explored to demonstrate the potential for health promotion.

Legal issues arising in community nursing 8: removal to a place of safety

The community nurse may be confronted with a situation where he/she believes that a patient should not be left on his/her own. In such a situation, there may be conflict between the individual’s right to make his/her own decisions and the need to protect the best interests of a mentally incompetent person or to protect public safety.

Pathways for continence care: background and audit

This article is the first in a series of three covering the use of care pathways for continence care. Trusts in Basingstoke, Swindon and Salisbury have collaborated in supporting their continence advisers in moving from finance-driven assessment data to evidence-based care pathways and the provision of patient information. This article identifies the background and approach to care pathways and addresses the quality issues. It details the issues facing continence advisers and how care pathways may help to address them. Furthermore, it describes a baseline audit which was carried out to ensure that facts rather than beliefs were being used and this demonstrated that little advice or treatment was actually reaching the patient.

The role of the nurse in urinary incontinence

Specialist nursing is dynamic and needs to be sensitive, flexible and responsive to changes in care delivery. Clinical, educational, managerial, audit and research activities are all integral to the role of the specialist continence nurse. Nurse specialists need to be careful that they do not de-skill the role of more generalist nurses, but rather enhance their contribution to continence care. They also need to work collaboratively with their Specialist Continence Physiotherapist colleagues. There is evidence that care in the community setting and on ward areas is sub-optimal. Recent audit activities have shown that nurses feel comfortable about assessing the person with continence problems but less certain about treatment. One way to address this imbalance is through the use of care pathways, examples of which are illustrated.