Notice to staff using a paper copy of this guidance The policies and procedures page of Healthnet holds the most recent and procedural version of this guidance. Staff must ensure they are using the most recent guidance.
Authors:
Manager, Minor Injury Unit, Cumberland Centre. Senior Nurse Practitioner, Minor Injury Unit, Cumberland Centre. 588
Asset Number:
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Circulation List
Consultation Process
Equality Analysis Checklist completed References/Source Supersedes Document Author Contact Details
Please note if this document is needed in other formats or languages please ask the document author to arrange this. MIU staff, A&E Consultant, Pharmacist, Microbiologist, REI, Paediatric, ENT, Dentists, Radiography, Family Planning and GPs. Extensive research for best evidence and practice Yes initial screening assessment: full assessment not required Clinical protocol reference list V.3 By post: Local Care Centre Mount Gould Hospital 200 Mount Gould Road Plymouth Devon PL4 7PY
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Document Review History Version Type of No. Change 1.0 Handbook of clinical protocols v0.2 Updated and published Date September 2005 September 2008 Originator of Change Original Service Development Manager MIU/ MIU Clinical Lead MIU Clinical Lead Clinical Lead Review Team Description of Change
V 2:1
Updated
March 2009.
2:2
August 2010
October 2010 Clinical Lead ED Consultant April 2011 July 2012 Policy Ratification Group Senior Nurse Practitioner ED Consultant
Current protocols reviewed and updated New protocols included to meet service need Current protocols reviewed and updated from best evidence/experts New protocols included to meet service need Minor amendments to various protocols within the document from various clinical experts Minor amends. Added Shoulder Protocol
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INDEX FOR MIU HANDBOOK OF CLINICAL PROTOCOLS INDEX TO MIU HANDBOOK OF CLINICAL PROTOCOLS 1. INTRODUCTION 2.PURPOSE 3.DUTIES 4. DEFINITIONS : Experience and education Scope of nursing practice When to refer to a GP When to refer to PHT Discharge Discharge against advice Transfer of patients Appendix 5 DOCUMENTATION PROTOCOL PROTOCOLS : ANAPHYLAXIS ASTHMA ADULTS AND CHILDREN BOILS, CARBUNCLES, FOLLICULTIS, PARONYCHIA CALF PROBLEMS/INJURIES - TRAUMA AND NON TRAUMA CHEST PAIN CHEST INJURY - MUSCULOSKELETAL DAMAGED OR MISSING TEETH DENTAL PAIN DENTAL ABSCESS EAR ACHE PROTOCOL MANANGEMENT PATHWAY FURUNCLE (BOIL) EAR CANAL PERFORATION OF TYMPANIC MEMBRANE ACUTE OTITIS EXTERNA ACUTE OTITIS MEDIA VIRAL EAR INFECTION EAR WAX PROTOCOL ECZEMA PROTOCOL INFECTED ATOPIC ECZEMA ACUTE ATOPIC ECZEMA SEBORRHOEIC ECZEMA POMPHOLYX ECZEMA CONTACT DERMATITIS ALLERGIC CONTACT DERMATITIS ELECTRICAL INJURIES AND LIGHTENING STRIKES EPISTAXIS EMERGENCY HORMONAL CONTRACEPTION FOREIGN BODIES IN EARS - REMOVAL FOREIGN BODIES IN THE NOSE - REMOVAL SIMPLE FRACTURES AND INJURY MANAGEMENT Minor Injury Unit Handbook of clinical protocols Version 3.1. 4 9 9 10 11 11 12 13 13 14 14 15 15 16 20 22 25 28 30 32 34 35 36 37 38 39 39 39 40 40 42 43 44 44 44 44 44 45 47 49 50 55 56 57
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GENERAL MANAGEMENT MANAGEMENT OF SPECIFIC UPPER LIMB FRACTURES 1ST MC 5TH MC OTHER MC ALL PHALANX # DISTAL PHALANX DISLOCATIONS OF PROXIMAL AND DISTAL IPJ WRIST SCAPHOID RADIUS AND ULNA ISOLATED # MIDSHAFT EITHER RADIUS AND ULNA RADIAL HEAD/NECK SUPRACONDYLAR/CONDYLE/EPICONDYLE OLECRANON PULLED ELBOW SHOULDER INJURIES HUMERUS CLAVICLE AC JOINT DISRUPTION SCAPULA SHOULDER X-RAY NON TRAUMA SHOULDER PAIN SUSPECTED SOFT TISSUE INJURIES AND PROBLEMS AROUND THE SHOULDER SUB ACROMIAL IMPINGEMENT (Painful Arc Syndrome) EPIPHYSEAL # IN CHILDREN MALLET FINGER BOUTONNIERE FINGER MANAGEMENT OF SOME NON TRAUMA UPPER LIMB PROBLEMS MANAGEMENT OF SPECIFIC LOWER LIMB FRACTURES # NECK FEMUR # SHAFT OF FEMUR AVULSION # TIBIAL SPINE # OR DISLOCATION OF PATELLA OSTEOCHONDRAL # KNEE INJURIES/MANAGEMENT KNEE XRAY # TIBIAL PLATEAU ISOLATED # UPPER OR MID SHAFT FIBULA # TIBIA AND FIBULA STRESS FRACTURE TODDLERS # MANAGEMENT OF LIMPING CHILD Minor Injury Unit Handbook of clinical protocols Version 3.1.
57 58 58 58 58 58 59 59 59 60 60 60 61 61 61 61 63 63 64 64 64 65 65 65 66 67 67 67 67 68 68 68 68 68 68 68 68 69 69 69 70 70 70
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ANKLE INJURIES BILATERAL # #CALCANEUM # BASE 5th MT OTHER # MTs METATARSAL STRESS FRACTURES # TALUS/SUBTALAR/MIDTARSAL FOOT XRAY PHALANGES FRACTURES DISLOCATIONS TO PROXIMAL OR DISTAL IPJ TOES EPIPHYSEAL # IN CHILDREN QUADRICEPS HAEMATOMA TENDON INJURIES TO LOWER LIMB MANAGEMENT OF SOME NON TRAUMA LOWER LIMB PROBLEMS FRACTURE NOSE FUNGAL INFECTIONS ATHLETES FOOT NAIL INFECTIONS RINGWORM GROIN INFECTION GASTROENTERITIS MINOR HEAD INJURIES HEADACHE HEAD LICE HERPES VIRUS COLD SORE GINGIVOSTATITIS CHICKEN POX SHINGLES POSTHERPETIC NEURALGIA IMPETIGO INGESTED FOREIGN BODIES INGROWING TOENAIL MENINGITIS (SUSPECTED) NAIL INJURIES NAPPY RASH NECK WHIPLASH INJURIES NECK PAIN OPHTHALMIC INJURIES AND PROBLEMS OPTHALMIC FOREIGN BODIES INFECTIVE CONJUNCTIVITIS ALLERGIC CONJUNCTIVITIS CHEMICAL SPLASHES POISONING PSORIASIS RESUSCITATION - ADULT AND CHILD BASIC LIFE Minor Injury Unit Handbook of clinical protocols Version 3.1.
70 71 71 71 71 71 71 72 72 72 72 72 73 73 74 77 77 77 77 78 78 85 88 90 90 91 92 92 93 93 95 96 97 98 102 102 103 106 106 106 107 107 108 109 110 111
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SUPPORT CHOCKING - ADULT AND CHILD SCABIES SINUSITIS NASAL CONGESTION VIRAL SINUSITIS ACUTE BACTERIAL SINUSITIS OVER 12 YEARS ACUTE SINUSITIS UNDER 12 YEARS SORE THROAT EPIGLOTTITIS QUINSY SCARLET FEVER GLANDULAR FEVER LARYNGITIS VIRAL INFECTION ACUTE TONSILLITIS TAMPONS REMOVAL OF LOST URTICARIA - ACUTE AND CHRONIC UTI URINARY RETENTION RENAL/URETERIC COLIC SUSPECTED URINARY INFECTION IN A PATIENT WHO IS PREGNANT REPEAT EPISODES OF URINARY SYMPTOMS ADULT MALE PATIENTS UTI IN OTHERWISE HEALTHY PATIENT PROBABLE UTI IN HEALTHY CHILD OVER 5 ACUTE CYSTITIS WART AND VERRUCA WOUND MANAGEMENT ABRASIONS BITES ANIMAL AND HUMAN BURNS AND SCOLDS FOREIGN BODIES IN WOUNDS HIGH INJECTION WOUNDS PULP INJURIES OF THE FINGERS PUNCTURE WOUNDS (MINOR) STINGS INSECT AND FISH SPECIFIC LACERATION MANAGEMENT WOUND CLOSURE MANAGMENT DRESSING MANAGEMENT OF INFECTED WOUNDS TETANUS COMBINED VACCINE X-RAYS (NURSE REQUESTED) 6. REFERENCES 7.MONITORING COMPLIANCE AND EFFECTIVENESS 8. ASSOCIATED DOCUMENTATION Minor Injury Unit Handbook of clinical protocols Version 3.1.
113 114 116 117 117 117 117 118 119 119 120 120 120 120 121 121 123 124 125 126 127 127 127 127 128 128 130 131 131 132 133 135 135 135 135 136 137 138 139 140 141 144 146 160 160
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9. LEAD AND SERVICE MANAGER SIGNATURES 10. APPROVAL AND GOVERNANCESIGNATURES APPENDIX A = MIU STAFF SIGNATURES APPENDIX B = LIST OF AGREED ABBREVIATIONS APPENDIX C= PATIENT INFORMATION LEAFLETS APPENDIX D = ALGOYTHM CARE PATHWAY APPENDIX E = GUIDELINES FOR THROMBOPROPHYLAXIS IN ADULT CASTS IN A LOWER LIMB AND VENOUS THROMBO-EMBOLISM RISK ASSESSMENT APPENDIX F = FALLS RISK ASSESSMENT TOOL APPENDIX G = REQUEST FOR IMAGES TO BE COPIED TO CD APPENDIX H= REI INDEX FOR REFERENCE REI RECORDING VA REI EXAMINATION OF THE EYE REI EYE IRRIGATION REI APPLYING AN EYE PAD REI REMOVAL OF CONJUCTIVIAL FB REI REMOVAL OF CONJUCTIVIAL,SUB TARSAL FB REI ADMINISTRATION OF LOCAL ANAESTHETIC REI- TREATMENT FOR ARC EYE REI INSTILLATION OF EYE DROPS REI INSTILLATION OF EYE OINTMENT APPENDIX I = MIU RECORD KEEPING AUDIT TOOL APPENDIX J - ADVICE LEAFLETS FOR SHOULDER MANAGEMENT
161 161 162 164 168 169 166 170 170 175 176 180 184 187 183 189 189 193 194 196 198 200
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2.
Purpose
The guidance provides a competency based clinical practice and professional framework for MIU staff. The purpose of these clinical protocols is to: Benefit specific patient groups that attend the MIU. Define the role and responsibilities of the nursing team, allowing for role expansion within clearly defined parameters, reinforced by appropriate medical and degree level education and practical experience. Define the range of minor injuries, illness and conditions appropriate for management and treatment. Define the process by which Nurse Practitioners may assess and treat patients within the individual clinical protocols only unless exclusions specified in the protocol exist. Patients excluded will need assessment and referring to the most appropriate healthcare provider i.e. General Practitioner, Dentist or Podiatry. Define the process by which nurse practitioners make emergency referrals and transport patients with acute trauma/medical problems on to Emergency Department (ED) in the Plymouth Hospital Trust (PHT). The clinical protocols provide all the up to date best evidence for safe clinical practice as advised with consultation with MIU staff and relevant healthcare professionals and appropriate verbal or written information to be provided for patients/carers. These protocols are working documents; developed and reviewed as
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appropriate and led by clinical lead and ED consultant. There is a minimum review period of two years.
3.
Duties
The Clinical Lead of the MIU is ultimately responsible for leading consultation, the producing and implementing of these protocols. The post holder will provide clinical leadership to the nursing team and by audit will ensure nurse practitioners work to and within these protocols. The Clinical Lead is responsible for leading the designing, drafting and developing of additional protocols in line with service and commissioning requirements. The post holder is responsible for leading two yearly reviews of the protocols. This will be done with the nursing team and by liaising with medical staff, pharmacy and other relevant healthcare professionals prior to ratification. Patient and public involvement with clinical protocol development is not expected. The clinical lead will coordinate auditing two yearly ensuring the nurse practitioners are working within the clinical protocols and feeding back results to Quality Improvement Group and individual MIU staff. Individual nurse practitioners will be registered nurses with current Nursing and Midwifery Council (NMC) registration. Nurse Practitioners will have undertaken appropriate degree level or above training to carry out clinical assessments of patients leading to diagnosis that requires treatment. They will have undertaken regular medical education training appropriate to the clinical protocols and Patient Group Directives (PGD) provided by Emergency Department consultant and annual training for anaphylaxis, BLS (adult and Paediatric) and Automated External Defibrillation (AED). It is the responsibility of the individual to keep up to date with continued professional development and attend regular planned in-house medical education sessions linked to clinical protocols and PGDs. Nurse practitioners have a responsibility for clinical diagnostic tests and to follow Trust current Diagnostic (clinical) Tests & Screening Framework . Reception staff are responsible for ensuring test results i.e. x-ray, urine tests and swab results, along with the clinical notes are given to the Nurse Practitioners to action/no action test results as per Trust Framework. The Nurse in Charge is accountable and responsible for ensuring safe practice when on duty; ensuring medical, pharmaceutical are checked, in date, clean and in good working order as per Trust current Medical Devices policy. The nurse practitioner in charge will be responsible and accountable for the management and leadership of staff during each shift. All nurse practitioners are responsible for the unregistered Health care Assistants (HCA) and reception staff, visitors, students and non Trust registered staff. They will work under nurse practitioner leadership and guidance, within the clinical protocols and are competent to carry out instructions, treatments and procedures as per NMC 2008 'The Code'. All patients should be assessed to confirm their capacity to make decisions
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regarding treatment in accordance with the Mental capacity Act 2005. The vast majority of patients will be deemed to have capacity; those who do not should be managed in accordance with the protocols described in the Act, involving other professionals as required. The patient must give verbal consent to be assessed without immediate involvement of a doctor and for information to be shared with other healthcare professionals. Verbal consent must be recorded on the casualty card. Written consent for some procedures will need to be gained prior to treatment being carried out i.e. suturing. If a patient (child or adult) is referred to social services ensure consent for sharing of patients information is gained.
4.
Definitions
The clinical protocols work alongside Patient Group Directives (PGDs). The PGDs allow nurse practitioners to supply approved medications to patients within a legal competency based framework. A Nurse Practitioner is defined as 'a senior registered professional nurse who has successfully completed additional degree level specific autonomous nurse practitioner training to carry out clinical assessments of patients presenting with minor injuries/illnesses that will require treatment and medicines'. An Assistant Practitioner is defined as 'a worker who competently delivers health and/or social care to and for people. They have a required level of knowledge and skill beyond that of the traditional healthcare assistant'. See Documentation protocol within the main body of the handbook of clinical protocols for full list of relevant abbreviations. A child is defined as a child until their 18th birthday.
CUMBERLAND MINOR INJURIES UNIT NURSE CRITERIA Experience and education The manager will undertake 24 hour responsibility for the MIU unit and clinical leadership. The manager will be a level one registered nurse with at least 5 years ED/MIU experience along with an appropriate management qualification. The clinical lead will provide clinical leadership to identified staff within the team. All registered Senior Nurse Practitioners and clinical lead will be a level one nurse with at least 3 years ED/MIU experience and will deputise for management as required. All registered staff will posses the ENB 199 or ENB 3 Accident and Emergency Nursing course or equivalent; the ENB 998 Teaching and Assessing Certificate/Mentorship module or equivalent; ENB A33 Developing Autonomous Practice (Emergency Nursing) or equivalent; BSc (Hons) Health Studies or above or be working towards; Child Protection level 2 or above; Adult Protection Alerters or Foundation course. All unregistered Healthcare Assistants will possess an NVQ3 in care or be working
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towards. Healthcare Assistants, students, visitors and any trained staff who are not NPs who will carry out any clinical procedure i.e. dressing changes, Plaster of Paris (POP) application will do so under the direction and supervision of the Nurse Practitioners. All registered and unregistered staff will undergo Trust and MIU induction programmes linked to Job descriptions (JD) and Knowledge and Skills Framework (KSF) appropriate to the post and grading. Assistant Practitioner role within the MIU will be a band 4 healthcare assistant who will undertake university foundation degree and provide additional support to the nurse practitioners and will provide a higher level of care to patients above that of the traditional healthcare assistant. The clinical lead will coordinate ongoing clinical medical education programme for all nurse practitioners; it is the nurse practitioners responsibility to ensure they receive regular medical training. The education programme will be linked to the clinical protocols, PGDs and competencies as well as up to date/current and relevant topics i.e. National Institute of Clinical Excellence (NICE) guidance. Safeguarding supervision programme and clinical supervision programme available for staff. All registered and unregistered staff will receive annual in house training and updates i.e. emergency planning, Basic Life Support (BLS adult and paediatric), Medical Devices and Infection Control. The clinical Lead will coordinate and arrange in house training and competency training for the Healthcare Assistants that will be linked to their Job Description and Knowledge Skills Framework. The Trust also provides other mandatory training opportunities and the clerical officer will co-ordinate training fro all staff. All MIU staff will have the opportunity to review their own personal development and training needs annually through an Individual Personal Performance (IPR) review and their three monthly management supervision sessions. Appendix A contains a full list of the MIU clinical staff. Staff are required to sign the appendix to indicate that the approved and ratified handbook of clinical protocols have been distributed and that they have read, understood and accept to work within these protocols. The HCAs and reception staff also sign the clinical protocols that they have read and accept to work under the direction of the nurse practitioners within the clinical protocols. Scope of nursing practice Registered nurses are to work to and within the Nursing & Midwifery Council 'The Code: Standards for conduct, performance and ethics for nurses and midwives (NMC 2008), The Prep Handbook (NMC, 2008), Standards of Medicine Management (NMC, 2008) at all times in their professional practice. As professionals, the registered nurses are personally accountable for their actions and omissions in their practice and must always be able to justify their clinical decisions. Failure to comply with 'The code' or other NMC standards, may, bring registered nurses fitness to practice into question and endanger their registration. All staff must work within the relevant Trust policy i.e.
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Infection Control Policy. Whilst the Trust has vicarious liability for the negligent acts and/or omissions for their employees, such cover does not normally extend to activities undertaken outside the registrants employment and may not extend to staffs practice outside of the protocols. The nurse may assess, treat and discharge patients without reference to a medical practitioner when working within this document and Trusts agreed clinical protocols and PGDs. The nurse practitioner will inform the patient of their role and obtain consent for treatment. Patients attending the MIU with problems of a general nature, which are outside of the nurses parameters of practice and competence, will be advised self-referral to consult a General Practitioner (GP) within normal working hours or Out of Hours GP service. If patients attend the MIU with medical and significant traumatic emergencies the nurse will liaise with the Plymouth Hospital Trust to arrange transfer to the most appropriate facility. All staff to be aware of Mental Capacity Act 2005 and the requirements for acting and making decisions on behalf of individuals who lack capacity to so themselves. As part of the National Service Framework (NSF) for Older People Standard 2: Person Centred Care a single agreed approach to assessment for health and social care all patients over 18 years attending the unit that require referral for a continuing care assessment will have a Background Information & Contact Assessment (BICA) by MIU staff . All reception staff has a responsibility to ensure test results, along with the patients casualty card are given to the Nurse in Charge when they arrive as per the current Diagnostic (clinical) Tests & Screening Framework. The Nurse in Charge is responsible for action/no action test and xray results and ensuring copies are sent to GP
WHEN TO REFER PATIENTS TO A GENERAL PRACTITIONER Patients (adult or children) should be referred to a GP/Out of Hours GP either the same day if urgent or the next available opportunity when they have: Any Illness or ailment that falls outside of these protocols and/or is of a chronic nature i.e. unwell, symptoms not settling/worsening or non specific pain etc. Localised and/or uncomplicated infections i.e. of the eye sustained more that 48 hours prior to attendance When referring a patient to the GP a copy of the clinical notes should accompany the patient. If referring the patient to the out of hours GP service a verbal referral is acceptable until a policy is available to use.
WHEN TO REFER PATIENTS TO A PLYMOUTH HOSPITAL TRUST Patients (adult or children) should be referred to Plymouth Hospital Trust when they
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have:
Any injury, acute Illness or ailment that falls outside of these protocols Serious multiple injuries, Pain that may be of cardiac origin/respiratory distress and/or cardiac arrest, Fractures that are outside of the protocol management (either displaced or angulated, involving potential nerve or blood vessel damage) All head injuries that fall outside the clinical protocols, Significant overdose and/or self-harm that requires medical management Acute medical emergencies i.e. acute abdominal pain, uncontrolled asthma, suspected stroke, diabetic coma, status epilepticus, Suspected and/or potential bony injuries in the absence of x-ray facilities, Patients with a suspected non-accidental injury refer to Safeguarding Children procedures (on Healthnet and in sub office). Severe acute pain of an unknown cause Potential penetrating eye injuries and corneal injuries (refer to Royal Eye Infirmary),
This list is not exhaustive and many other patients presenting to the unit may be referred to ED or other HCP at Derriford When referring a patient to the ED or REI a copy of the clinical notes should accompany the patient. Advice can be sought from senior medical staff at the Emergency Department of Derriford Hospital at any time. The person seeking advice should call (number 37777 option 4). The medical staff have access to X-rays via the WEBPACS system, and can advise on management of patients, referral and other matters
DISCHARGE
It is essential that patients have the opportunity to make informed choices about their care and treatment in the MIU and are fully aware of their aftercare needs following discharge. Discharge and treatment advice must be written clearly and in full i.e. rest 3/7 if no improvement to GP and any reviews must state where and when. All patients will receive oral/written information and instructions about their aftercare needs and medicines where appropriate. Health Promotion and or Education advice must be written clearly and in full with any referral recorded. A letter of treatment must be written and sent to the patients General Practitioner within 24 hours of attending the MIU. For all children age under 5 years, information about their attendance will be routinely shared with the childs Health Visitor with a copy of the discharge letter. All children 5 + will only have attendance information shared with the school nurse if there is an open episode with that child or if there is a need to refer the child to school nursing service. For all children under 18 years, consent will be obtained to share information about their attendance as required for 0-19 service, HV or social services as per the current
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Safeguarding Children: Management of Frequent Attendances Policy. This will be by telephone conversation and followed up with a letter or referral. A copy of the clinical records to be sent to Trust Named nurse if there is child protection concerns at the time of presentation or child referred to social care. If a patient (child or adult) is referred to social services an information sharing form must be completed and consent for sharing of patients information signed. Refer to regional and local policies for any Child Protection issues available on the Healthnet or in paper form in unit.
DISCHARGE AGAINST ADVICE Patients have the right to discharge themselves against advice or before they have been treated. A record of the reasons for the patients discharging themselves against advice will be made on the casualty card, including information on treatment offered/accepted and the names of staff involved. Wherever possible, staff should ask the patient or carer to sign the casualty card or a self-discharge slip before they leave the unit. When the severity of a patients condition demands treatment, and there is concern about their ability/mental capacity to make an informed choice then advice should be sought from Plymouth Hospital Trust/Social Services/Mental Health Services and/or Police about how to progress.
TRANSFER OF PATIENTS When Transferring Patients: All relevant documentation relating to the patients care including a copy of the casualty card, X-ray Web Pac number if taken, should accompany the patient. If the outpatient appointment is more than one working day, the notes must be sent with the patient and/or current transport arrangements - this must be recorded and signed in the casualty card. When transferring always document on the patients casualty card: the time, mode of transfer for the patient and notes for audit purposes. A verbal referral and handover to other Healthcare professionals such as Ambulance personnel is acceptable until a policy is available to use. Appendix A = Contains a full list of the MIU clinical staff with signatures Appendix B: = Contains a list of abbreviations that may be used within clinical records Appendix C: = Contains a list of current patient advice leaflets Appendix D: = Contains an algorithm of the patients pathway of care through the MIU Appendix E = Guidelines for thromboprophylaxis in adult casts in a lower limb and Venous thrombo-embolism risk assessment Appendix F = Falls Risk Assessment Tool Appendix G = Request for Images to be copied onto CD
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Appendix H = REI Protocols for Clinical Practice Appendix I = MIU Record Keeping Audit Tool
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5.
DOCUMENTATION PROTOCOL
All registered nurse practitioners will adhere to The Prep Handbook 2008; NMC The Code: Standards of conduct, performance and ethics for nurses and midwives 2008 relating to keeping clear and accurate records. To work within NMC Guidelines for Records and Record keeping (2005) and any future versions; the Trusts current Clinical Record and Note Keeping Policy, the current Health Record Audit Tool; and the current Safeguarding Children: Management of Frequent Attendances Policy. All registered nurse practitioners and unregistered staff will receive in house record keeping training as part of their MIU induction programme to ensure their knowledge and skills of record keeping complies with Trust and local policy. All patients supplied with medicines must have their medicines recorded on the casualty card and in the Pharmacy Reconciliation folder as per Trusts current Medicines Management Procedure. It is all staffs responsibility and accountability to maintain their own record keeping as per guidance and policies. Registered and unregistered staff will receive Trust and unit induction and annual mandatory record keeping training as per policy. The casualty cards or clinical records will be audited annually to ensure registered and unregistered staff compliance - see Appendix I. The MIU currently uses casualty attendance card to record clinical details and is of vital importance as a historical record of a patients treatment in the MIU and may be called upon years after a treatment episode to provide evidence in a court of law, litigation procedure or inquiry. Staff to complete pre -treatment assessment and any risk assessments pertaining to the patients presenting complaint i.e. thromboembolism risk assessment. It is documented if a patient/carer declines/refuses to give any of the requested information The Casualty Card record will contain the following demographic information as a requirement:Name, date of birth, sex, full address (temporary address if not local), telephone number (landline and/or mobile) and National Health Service number. DOB, ethnic group, gender, marital status and occupation will also be documented along with General Practitioners name, address and telephone number. Children under 18 years must have the name and relationship of accompanying adult, name of next of kin and name of person with parental responsibility and social history. The name of the child's school and if known the name of school nurse, HV or Social Worker if applicable (names of HV and school nurses can be found on shared drive and in paper form in unit) aswell as above demographic details. All adults to be asked at time of attendance if they have or care for children as their injury/illness may impact on their ability to care for their children. If clinical decision made not to ask the question this must be documented. All clinical records must be clear, concise, accurate, legible, written in black ink only and be free of ditto marks The Casualty Card record will contain the following information as a requirement:-
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All pages of the casualty card must be fully identified with unique patient identifier e.g. NHS number, DOB, Epex number and be dated chronologically. The time of patient's arrival and first contact with the service using 24 hour clock. The HCA must carry out and document initial assessment of the patient along with all timings to ensure that they are safe to wait to be seen by NP - all appropriate observations and weight of a child must be recorded and any ring FB removal, first aid, pain score recorded and any actions taken noted. The nurse practitioner must check ePEX for all children under 18 years and record in the notes checked for safeguarding concerns or other service interaction with that child. If Child protection concerns at the time of attendance or if staff refer the child to social care then a copy of the notes to Named nurse. The Nurse Practitioner must write all times of contacts with the patient using the 24 hour clock e.g. consultation commenced , sent to xray, returned from xray, conversation with other HCP/services and time disposed. Transfer and Transport times. Consent to treatment and/or sharing of information with other HCP or services must be recorded and forms completed All Nurse Practitioners must inform the patient of role the nurse practitioner and obtain consent for treatment History from patient/child/carer relating to presenting injury/illness, along with Past medical history, allergies, medication and immunisations must be recorded. The casualty card must be written chronologically and treatment written in full and duration i.e. rest 3 days and if no improvement to see own GP. Medicines supplied under protocols/PGD must include advice on using and/or over the counter drugs. Advice for patients to return for follow up if problem is not settling within a stated time scale must be written in notes. All staff must sign any entries made with printed name and designation in full at least once in the record. Any mistakes must be crossed through once with a single line and signed and dated. Only locally agreed abbreviations linked to clinical protocols used (list of abbreviation in Appendix B) No other abbreviation can be used. All coding boxes pertinent to current casualty card and IT system must be completed that correlate with the clinical records, investigations undertaken and treatments supplied, discharge transport, discharge times and disposal/referrals and initialled by receptionist when data inputting completed All patients transferred to ED will need to have an Identification Band as per Patient Identification Protocol and ensure all records including medication supplied are photocopied and sent in a sealed envelope with the patient. All patients must have a GP letter written by the NP and sent by receptionist to the correct GP practice All children under 5 years will require a letter to the Health Visitor. All other discharge plans as per clinical decision by the nurse practitioner. Staff to follow current safeguarding children standards - see intranet for policies If a child fails to attend an appointment (dressing or clinic) a did not attend letter must be written and sent and a record kept in notes.
All casualty cards will be stored according to policy - in a systematic competent filing system, securely attached notes and stored in lockable cabinet within a lockable room ( until a another system of storage is available).
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All casualty cards will be scanned 6 monthly onto CDrom and the CDrom stored again according to policy - 8 years for adults and until child's 25th birthday or 26th if child was 17 years at the time of treatment or 8 years after the child's death. The casualty cards will be destroyed under confidential conditions and a certificate of destruction will be supplied by the company A data base of any destroyed records should be available. This documentation protocol also links to: Adult Protection/Safeguarding Adults Multi-agency Policy & Procedures Infection Control policies Anaphylaxis protocol (management of severe) Child Protection (Multi-agency) Handbook Clinical Record a& Note Keeping Policy Confidentiality Policy Diagnostic (Tests) and screening framework Epex Policy - Children and Families Services Coding Manual Infection Control policies Major incident plan Medical Devices Management policy Medicine Management Procedure Patient Group Directions Policy Patient Identification Protocol 2008 Resuscitation policy Mental Capacity Act 2005 National Service Framework for Older People Safeguarding children: Management of Frequent attendances to MIU The Medical Model of assessment will be used by the Nurse Practitioner this includes: PC: HPC: Presenting complaint History of complaint and time elapsed from whom History provided (patient, parent, carer) Past medical history Allergies known Tetanus status Current Medication- if any or document nil Dominant hand for all upper limb injuries Full clinical assessment to include: LOOK, FEEL, and MOVE. LOOK: any deformities, abnormalities, length, size and depth of lacerations and wounds, colour of any bruising, colour of limb or area, swelling limb or area, swelling sensation, tenderness, pulses, neurovascular, warmth.
PMH:
EXAMINATION:
FEEL:
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MOVE:
passive and active range of movements, strength/power, Use anatomical stamps (if available) to complement findings Record relevant negative findings- e.g. no bruising, no bony tenderness. BP, pulse, respiration, and temp. Oxygen Saturation Levels, Pupil reaction, Peak flow, BM test as appropriate. Pain score And weight as required to be recorded for children/infants requiring pain management ECG, MSU, Urinalysis, Wound swab, Pregnancy Tests, xray Document clinical impression if unable to diagnose condition To be given in full and duration, any actions to be taken if no improvement. Any medicines supplied and administered in accordance with the specified protocol and Patient Group Directive, must be written in full, the dose: to include length of course, route of administration, date, time given, including advice on using drug, side effects and action to take - this should be signed by the nurse. Drugs must be recorded in the pharmacy reconciliation folder. Disposal documented and any follow-up review/transfers must state where, when and to who Referrals and transfers - to whom, any transport requirements with Times - identification bands as per protocol Discharge times, advice written and oral with return by dates Any social circumstances/concerns either adult or child refer to appropriate HCP/service. Legible, written in black ink, print name and designation in full use stamps if available All coding boxes must be completed on the reverse of the casualty card that correlates with clinical notes; investigations, treatments, discharge transport, discharge times and disposal/referrals Must be completed correctly on all cards with mandatory fields accurate (i.e. times)
Observations:
Investigations:
Disposal to include:
Signature: Coding:
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ANAPHYLAXIS
Anaphylactic shock is a 'severe, life threatening generalised or systemic hypersensitivity reaction' - The European Academy of Allergology and Clinical Immunology Nomenclature Committee. Occurs when histamine is released, usually as part of an immediate hypersensitivity reaction. Clinical features may include:Flushing, urticaria, itching, headache, tachycardia, wheeze, broncho-spasm, angiooedema/oedema of face and eyes and hypotension. Anaphylaxis can be triggered by any of a very broad range of triggers but those most commonly identified include, food, drugs and insect venom. Severe cases with airway obstruction require oxygen, electrocardiogram (ECG) monitoring and immediate treatment. Treatment for severe anaphylactic shock is the administration of Adrenaline (Epinephrine) 1/1000 injection intramuscularly in the first instance. MANAGEMENT As per Trust Anaphylaxis Protocol (management of severe) v 2:6 2008 Patient arrives at Reception and receptionist to recognise the patient is seriously unwell and arranges for them to be seen by a nurse practitioner immediately The nurse practitioner must discontinue administration of any suspect agent and carry out initial assessment and treatment. Treatment for any anaphylactic reaction should be based on general basic life support principles of Airway Breathing Circulation Disability Exposure (ABCDE) - call for help early and treat the greatest threat first. Initial treatments should not be delayed by lack of complete history or diagnosis. Diagnose look for Acute onset of illness Life threatening airway and or breathing And/or circulation problems Any unusual skin changes Life Threatening Problems Swelling, hoarseness, stridor Rapid breathing, wheeze, fatigue, cyanosis, SpO2 <92% confusion Pale, clammy, low blood pressure, tachycardia, faintness, drowsy/coma Sense of impending doom, anxiety, panic, decreased conscious level Erythema - patchy/generalised red rash
Call for help, lay the patient flat and raise their legs. Dial (9) 999 and summon an ambulance stating site address and full postcode. On no account should the patient be left alone.
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1st line medicine The nurse should administer the appropriate dose of Adrenaline 1/1000 IM as per PGD without delay and repeat after 5 minutes if no clinical improvement - follow anaphylaxis flow chart in Resuscitation room. Adrenaline MUST only be given by im route in the emergency treatment of anaphylactic reactions in the community settings as IV is potentially very hazardous and should only be given by specialist medical staff in a monitored environment. When skills and equipment available: Establish airway and breathing and administer Oxygen as per PGD if Oxygen saturation level below 94% (40% - 60% oxygen at a flow rate of 4-10 L/min depending on type of mask) with oxygen saturation monitoring to maintain SPO2 saturation 94% - 98%. Monitor blood pressure, pulse oximetry and ECG 2nd line Medicines Initial A, B, C, D, E assessment should not be delayed. The nurse should administer the appropriate dose of Chlorphenamine Maleate BP 10 mg Injection as per PGD. If hypotension is present and the nurse has cannulation skills, cannulate the patient. Use Sodium Chloride 0.9% injection as per PGD to flush following insertion. If cardio-respiratory arrest occurs after anaphylactic reaction start BLS immediately according to Resuscitation Council (UK) guidelines, ensure that (9 999) has been made for ambulance service. DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital DISCHARGE/TRANSFER Patients with severe or recurrent reactions who have required adrenaline, or patients with asthma will require hydrocortisone and should be admitted for observation - refer to Plymouth Hospital Trust (PHT) Emergency Department (ED). Ensure verbal hand over to paramedics of all treatment/management and medicines given. Ensure a copy of all documentation accompanies the patient with medicines clearly recorded. Ensure Identification Band N. B. if able advice the patient that all sufferers from anaphylaxis should be advised of the benefits of wearing some device such as a bracelet that will inform bystanders at the time of any future attacks. Precautions should be taken, where practicable, to avoid exposure to the suspected allergen. Patients should also be advised to discuss the need for an EPIPEN with the staff at hospital and/or GP
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Patients with severe or life threatening attacks, can sometimes appear undistressed therefore use AVPU (alert, voice responsive, pain, unresponsive) to assess condition but do not allow assessment to delay treatment. MANAGEMENT Patients with life threatening asthma should be managed as below; Telephone emergency services immediately for transfer to ED. Adults & Administer Salbutamol 5 mg, in with saline, via an oxygen driven Children >5 nebuliser as per PGD Children 2-5yr Administer Salbutamol 2.5 mg, in with saline, via an oxygen driven nebuliser as per PGD
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Give supplementary oxygen to all hypoxaemic patients to maintain and SpO2 level of 94-98%. The patient should be monitored using pulse oximetry. Children with SpO2 <94% should receive high flow oxygen via a tight fitting face mask an should be monitored using pulse oximetry. ACUTE SEVERE ASTHMA/ACUTE EXACERBATION Patients are deemed to be experiencing acute severe asthma or acute exacerbation if they display the symptoms listed below: ADULTS and Children Children >5 - 12 years Acute exacerbation > 12 years
Acute severe asthma
Children >2-5 Acute exacerbation SpO < 92% Too breathless to talk, Use of accessory neck muscles Pulse > 140 beats/min Respiration > 40 breaths/min
PEFR < 33-50% predicted or best Inability to complete sentences in one breath Pulse > 110 beats/min Respiration > 25 breaths/min
SpO < 92%, PEF < 50% best or predicted Too breathless to talk, Use of accessory neck muscles Pulse >125 beats /min Respiration > 30 breaths/min
MANAGEMENT Patients with acute severe asthma or acute exacerbation should be managed as below: Telephone emergency services immediately for transfer to ED. Adult Administer Salbutamol 5 mg with saline, via an oxygen driven nebuliser as per PGD or via spacer (4 -10 puffs given one at a time single puffs; repeated at intervals of 10-20 minutes) Children > 5 Administer 4-6 puffs given 1 at a time to a maximum of 10, of years Salbutamol via spacer at intervals of 10-20 minutes or 2.5 mg - 5 mg salbutamol with saline via an oxygen driven nebuliser as per PGD Administer 4-6 puffs to a maximum of 10, of Salbutamol via spacer or Children 2- 5 years 2.5 mg salbutamol with saline via an oxygen driven nebuliser as per PGD Give supplementary oxygen to all hypoxaemic patients to maintain and SpO2 level of 94-98%. The patient should be monitored using pulse oximetry. Children with SpO2 <94% should receive high flow oxygen via a tight fitting face mask and should be monitored using pulse oximetry. MODERATE ASTHMA/MODERATE EXACERBATION Patients are deemed to be experiencing moderate asthma or moderate exacerbation if they display the symptoms listed below ADULTS PEFR > 50% -75% predicted or best Children >5 SpO > 92% PEF . > 50% predicted Children 2-5 SpO >92% PEFR > 50% predicted or best
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MODERATE ASTHMA + UNCONTROLLED LESS SEVERE ASTHMA MANAGEMENT Patients with moderate asthma and uncontrolled asthma should be managed as below: Administer salbutamol 5 mg in 2.5mls with saline, via an oxygen driven nebuliser as per PGD (40 60% oxygen as per PGD) or via spacer (2 puffs given one at a time single puffs) Children > 2 puffs of salbutamol via spacer for uncontrolled asthma if unresponsive 2-18 years move to acute asthma management. Monitor good response 15-30, and 60 minutes after treatment and document PEFR, pulse, pulse oximetry and respiratory rate. If poor response after 15 minutes transfer by ambulance to the Emergency Department Assess patients ability to self-medicate i.e. uses inhaler. Supply TTA of Salbutamol inhaler if patients own supply is low/exhausted. If patients ability to self-medicate is unsatisfactory then refer patient to a doctor All children who have had a nebuliser must have follow up appointment by a doctor IF PATIENT IS TRANSFERED Ensure verbal hand over to paramedics of all treatment/management and medicines given. Ensure a copy of all documentation accompanies the patient with medicines clearly recorded. Ensure patient has an Identification band DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital DISCHARGE PLAN Prior to discharge check the following: Patients inhaler technique, Patients compliance with prescribed medication, patients understanding of asthma and principles of treatment. Patients who have recovered from a mild attack may be discharged from the department and should leave with advice and information on continued treatment. FOLLOW UP Advise the patient to seek medical advice if condition deteriorates and to attend GP the next morning or practice nurse asthma clinic as they may require a course of steroids. Adults
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MANAGEMENT, TREATMENT AND ADVICE Patients with a boil, carbuncle, paronychia folliculitis or staphylococcal whitlow should be managed as below: FOLLICULITIS superficial staphylococcal Aureus infection of the hair follicle which develop into small inflammatory papules/pustules - sites commonly affected are scalp, extremities, perioral, perinasal, buttocks, axilla and medial thighs (CKS, 2007) A papule or pustule Explain that the patient should avoid aggravating factors pierced by a single i.e. tight clothing, plasters, shaving hair. Often occur in Advice patient to wash daily with an antiseptic product crops and the such as Savlon or TCP Antisepic Liquid pustules can form Treat patient if in pain i.e. paracetamol or ibuprofen crusts. May be painful Can treat localised folliculitis with Fusidic Acid cream or itchy. as per PGD or OTC and give advice re use and duration Systemic symptoms Treat severe/extensive folliculitis with Flucloxacillin as are rare per PGD or Erythromycin PGD if allergic to penicillin BOIL infection of a hair follicle from Staphylococcus Aureus(furnuncle) common areas affected face, neck, axilla, buttocks, groin and anogenital area Small red, hot tender (throbbing) inflammatory nodule with walled off purulent material arising from a hair follicle. Occasionally mild fever or malaise. Can exude pus and necrotic material. Can be single or in crops (CKS, 2007) Swab not required Non Fluctuant Advise patient to apply moist heat 3-4 times a day Paracetamol/ibuprofen for pain relief Treat with Flucloxacillin as per PGD or Erythromycin PGD if allergic to penicillin i Refer to ED if systemically unwell Incise and drain Fluctuant
(a wave like feeling on palpating skin overlying a fluid filled cavity with non rigid walls)
Swab for Culture &Sensitivity Inadine or equivalent dressing Paracetamol/ibuprofen for pain relief Refer to ED if systemically unwell
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CARBUNCLE Staphylococcus Aureus infection of a group of adjoining hair follicles which develops into a large swollen tender mass with multiple points draining pus (CKS, 2007) There may be swelling, inflammation in surrounding and underlying connective tissue. Common sites are back of neck, shoulders, hips, thighs may have pain or itching. Systematic symptoms are rare Swab not required Non Fluctuant Advise person to apply moist heat 3-4 times a day Paracetamol/ibuprofen for pain relief Treat with Flucloxacillin as per PGD or Erythromycin PGD if allergic to penicillin Refer to ED if systemically unwell or GP for review Fluctuant or sites of Refer to ED multiple pus discharge ACUTE PARONYCHIAinfection of the skin and soft tissue bordering the proximal and lateral nail fold from Staphylococcus Aureus (CKS, 2007) The skin and soft tissues at the base of the nail is red, hot and painful with swelling and possibly a visible collection of pus. In severe cases pus may extend to the proximal nail edge, abscess formation with fluctuance and subungual abscess. Nail may be discoloured or distorted Non Fluctuant Do NOT Incise and drain If discharging swab for Culture and Sensitivity Advise person to apply moist heat 3-4 times a day High Arm Sling/Elevate Paracetamol/ibuprofen for pain relief Treat with Flucloxacillin as per PGD or Erythromycin PGD if allergic to penicillin Refer to ED if systemically unwell Incise and drain Fluctuant Swab for Culture and Sensitivity Inadine or equivalent dressing High Arm Sling/Elevate Paracetamol/ibuprofen for pain relief Refer to ED if systemically unwell Beware chronic paronychia - this is often fungal and does not respond well to the above treatment. It is most common in hairdressers STAPHLOCOCCAL WHITLOW an abscess of the fleshy area of the palmer aspect of the fingertip from Staphylococcus Aureus (CKS, 2007) The finger pulp is red but not extending to DIPJ, hot oedematous. Significant pain and tenderness due to swelling in the pulp of the fingertip. The onset of pain is rapid, sever and throbbing. May be evidence of penetrating trauma. Pointing abscess may be present and self draining. Paronychia may be present Non Fluctuant Swab not required
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Fluctuant
Advise person to apply moist heat 3-4 times a day High Arm Sling/Elevate Paracetamol/ibuprofen for pain relief Treat with Flucloxacillin as per PGD or Erythromycin PGD if allergic to penicillin Refer to ED if systemically unwell proximal lymphangitis/cellulitis or joint involvement Incise and drain Swab for Culture and Sensitivity Inadine or equivalent dressing High Arm Sling/Elevate Paracetamol/ibuprofen for pain relief Treat with Flucloxacillin as per PGD or Erythromycin PGD if allergic to penicillin Refer to ED if systemically unwell proximal lymphangitis/cellulitis or joint involvement If Whitlow recurs after draining then refer to plastics SHO as may be collar stud abscess which requires exploration
Give general advice to all patients about using antiseptic preparations and daily skin washing. Ensure drugs supplied are recorded in the clinical notes and in the pharmacy reconciliation folder. Routine GP letter to be written and sent DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital REFERRAL AND FOLLOW UP If patient suffers from recurrent or chronic boil, carbuncle, folliculitis, paronychia or staphylococcal whitlow or is suspected of Staphylococcal carriage, refer them to their General Practitioner.
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Rest for 3-5 days from strenuous exercise Advise gentle mobilisation/walking and
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Pain to calf on dorsiflexion and standing on tiptoes No signs and symptoms of DVT
massage area Elevate limb Ice area 3-4 times a day for 3-5 days Double tubigrip for 5 days Advise OTC analgesia paracetamol/ibuprofen or as per PGD Follow up GP within 3 days if no improvement
CELLULITIS Common in the elderly especially patients with vascular problems or skin ulceration Refer the patient to GP or ED if Subacute or more gradual onset. systemically unwell Sometimes proceeded by local infection such as spot or insect bite. Lower leg swelling, redness, warm/hot Ascending lymphangitis, high temperature >37C TRAUMA GASTROCNEMIUS Soleus Muscle complex (large muscle complex at the back of the calf) (tennis leg) SPRAIN/TEAR Common sports injury: patient feels a sudden 'blow' or 'kick' to calf whilst lunging forward and the overload causes a sprain/tear. Frequently occurs in Tennis, badminton, squash, volleyball and other jumping sports Vigorous take offs or jump ups causes overload and sprain/tear Walks on ball of foot with knee bent Usually resolves spontaneously therefore Pain on stretching muscle and passive Rest from sport until asymptomatic dorsiflexion Supply Crutches for 3-5 days only if Pain in calf when rising on tiptoe unable to bear weight Tenderness at sprain/tear on palpation Use orthopaedic felt to raise heel by usually medial head of gastrocnemius in approx 1 cm in both shoes the middle/upper calf Ice area 3-4 times a day for 3-5 days Swelling and may bruise Advise analgesia - paracetamol or Possible palpable gap ibuprofen Difficulty in weight bearing Follow up GP within 5 - 7 days if not Normal Achilles function settled. Physiotherapy may be required later Advise stretching exercises from about 3 weeks after incident if pain has resolved. If increase in pain or symptoms to attend ED for assessment DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital DISCHARGE PLAN Written instruction leaflet on soft tissue injury care Guidelines should be given to the patient about any abnormal signs/symptoms to observe and if required when to arrange follow-up with General Practitioner.
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CHEST PAIN
ASSESSMENT When the patient arrives at reception with chest pain the receptionist will arrange for them to be seen by a nurse practitioner immediately. The nurse practitioner must carry out an initial assessment and commence immediate management and treatment for those patients suffering from any recent chest pain or discomfort of suspected cardiac origin. When assessing a patient, you should: Assess the patient using ABCDE THIS MUST NOT DELAY THE TRANSFER OF PATIENT TO THE ED PLYMOUTH HOSPITAL TRUST Patients with chest pain and/or acute coronary syndrome should be assessed as below: Assess patient's immediate needs and take a brief history Patients complaining of current crushing chest pain and/or radiation to jaw or arms should be considered to have cardiac pain until proven otherwise Check the history of the pain; nature, site, severity, onset time and whether abrupt or gradual, activity at time, whether still current current, or duration and timing if settled. Any recent history of ischaemic heart disease or treatment. Previous chest pain Beware if accompanied with any of the following clinical signs Shortness of breath / difficulty breathing/breathlessness Nausea and/or Vomiting Sweating / pallor / weakness Pain or altered sensation radiating to arms, neck or jaw. MANAGEMENT IMMEDIATE MANAGEMENT OF SUSPECTED CARDIAC PAIN - as per NICE guideline 73 Call 9 999 and give ambulance service clinical history, site address and postcode Record observations: pulse, heart rhythm, BP, RR, pulse oximetry and oxygen saturation - continue to monitor Record 12 lead ECG - as a baseline. A normal ECG does not exclude acute coronary syndrome Administer pain relief: GTN as required according to GTN PGD Administer a single loading dose of 300mg aspirin unless the patient is allergic as per Aspirin PGD Do not routinely administer oxygen but monitor saturation levels using pulse oximetry as soon as possible. Only offer supplementary Oxygen as per PGD to patient with SpO2 of > 94% (88-92% in patients with known COPD) who are not at risk of hypercapnic respiratory failure aiming for SpO2 of 94-98%. Continually observe airway, breathing and circulation - BLS if required Pulse oximetry and monitoring
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Cannulate and flush if nurse practitioner has competency to do so - see Sodium Chloride PGD Contact next of kin if not present Handover to ambulance staff and give a copy of the casualty card with drugs administered and ECG Inform ED of patients transfer for monitoring and management
TRANSFER Ensure verbal hand over to paramedics of all treatment/management and medicines given. Ensure a copy of all documentation accompanies the patient with medicines clearly recorded. Ensure patient has an Identification band DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital Ensure drugs are recorded in the clinical notes and reconciliation folder N.B This protocol is for guidance only: due to the nature and severity of the patient complaint some actions/management may be taken out of sequence or done by more than one healthcare professional (registered and/or unregistered) simultaneously
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Patients with mild musculoskeletal chest pain should be managed as below: Mild difficulty in breathing Worsening pain on deep breathing, coughing and moving Bruising to chest wall Record temperature, pulse, BP Pulse Oximetry and respiration rate Look, listen and feel chest Supply analgesia according to patients
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needs either OTC or as per PGD Written and verbal Chest wall advice
DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital
DISCHARGE PLAN All patients who are not transferred should leave the department with the following information: Written and verbal advice/instructions on chest wall injury. Guidelines and actions to be taken on abnormal signs/symptoms and when to see a doctor and within a set time scale.
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DENTAL PAIN
EXCLUSIONS Patients that attend the MIU with dental pain sustained from trauma. Patients with: Associated swelling Dysphagia Systemic evidence of infection (fever, systemic illness etc.) Post extraction haemorrhage For these patients, contact their dental practitioner or on call Maxillofacial surgeon for advice on the appropriate treatment.
ASSESSMENT When assessing a patient, you should: Inform patient of role of nurse practitioner and obtain consent for treatment Undertake a pre-treatment assessment in accordance with MIU documentation protocol
MANAGEMENT AND DISCHARGE PLAN Patients with Dental pain should be managed as below: Advice OTC analgesia or supply TTA pack of analgesic as per pain score and appropriate analgesia PGD Advice the patient to attend their dental practitioner as soon as possible If the patient does not have a dentist advise them to contact the Dental HelplineMonday Friday 9-6.30 0845 155 8070 Monday Friday 6.30 10 01392 823682 All Day Saturday and Sunday 01392 823682
DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital
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DENTAL ABSCESS
ASSESSMENT When assessing a patient, you should: Ask the patient if they have seen a dentist recently. MANAGEMENT AND DISCHARGE PLAN Patients with Dental abscesses should be managed as below: The Association Dental Practitioners recommend that a dentist and not nurse practitioners prescribe antibiotics therefore: Advice patient to attend their dental practitioner If patient does not have a dentist advise them to contact the Dental HelplineMonday Friday 9-6.30 0845 155 8070 Monday Friday 6.30 10 01392 823682 All Day Saturday and Sunday 01392 823682 Advice OTC analgesia or supply TTA pack of analgesic as per pain score and appropriate analgesia PGD.
DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital
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MANAGEMENT PATHWAYS If oropharynx painful, red or inflamed Go to protocol for Sore Throat
Ear canal can be swollen shut discharge associated with reduced hearing and parathesia along jaw line Ear canal can be red, inflamed, itchy or moist, associated with normal ear drum (if visible) or mild discharge Localised swelling seen in outer third of ear canal associated with severe pain on palpation of tragus or jaw movement Tympanic membrane is bulging / retracted, red or fluid level noted and associated with severe pain, temperature >37 c, maliase, hearing loss, mucoid discharge Perforation is seen associated with transient ear pain; hearing loss; bloody discharge but temperature normal and patient does not feel unwell Tympanic membrane is pink but not retracted or bulging associated with mild to moderate pain, temperature <37o C or coryza
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TREATMENT AND ADVICE Patients with a furuncles, perforation, acute otitis externa, otitis media or viral ear infections should be treated as below: FURUNCLE (BOIL) IN EAR CANAL (CKS, 2009) Painful localised swelling in ear canal Pain worse on jaw movement or palpation of tragus. Treat with Flucloxacillin as per PGD Ensure all women taking oral contraceptive pill are advised on extra precautions Treat pain and fever with paracetamol OR ibuprofen if not contraindicated (OTC or see relevant PGD) Advice that ear may discharge Advice on the use of local warmth Treat with Erythromycin as per PGD
PERFORATION OF TYMPANIC MEMBRANE (CKS, 2009) Transient ear pain Hearing loss Bloody discharge Eardrum visibly perforated but temperature normal and patient does not feel unwell. Advice that perforation will usually heal spontaneously. Healing enhanced if ear canal kept clean and dry. Treat pain and fever with paracetamol OR ibuprofen if not contraindicated (OTC or see relevant PGD) Advice no swimming or diving until ear has been reexamined and healing confirmed. Keep water from entering ears whilst showering/ hair washing Advice if the pain increases or bloody discharge persists consult their General Practitioner or OOH Advice patient to be followed up by GP after 2 weeks Then treat with Amoxycillin as per PGD, for patients with penicillin sensitivity; see erythromycin PGD.
ACUTE OTITIS EXTERNA (CKS, 2009) Pain on palpation of tragus; Hearing loss; Ear canal can be swollen, red, inflamed, itchy or moist; Ear drum if visible is normal; Mild discharge may be present. Swab any discharge gently away. Perform aural toilet to remove debris from ear canal Check that ear drum is not perforated. Treat with Locorten-Vioform ear drops for 7 days, as per PGD Treat pain and fever with paracetamol OR ibuprofen if not contra indicated (OTC or see relevant PGD) Advice no swimming whilst ear inflamed and explain swimming may precipitate further attacks Keep water from entering ears whilst showering / hair washing
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ACUTE OTITIS MEDIA (AOM): Bacteria or Viral Infection of the middle ear characterised by the presence of middle ear effusion and inflammation (CKS, 2009) Pain and/or earache; Consider whether antibiotics are required: Temperature elevated Most patients presenting with suspected acute otitis >37o C; media advise no antibiotic strategy or a delayed Mild malaise antibiotic strategy - inform the patient that the average Hearing loss; time illness for untreated AOM is 4 days. Advise Mucoid ear discharge; review in MIU or GP if no improvement in 4 days and Ear drum is red, yellow then treat with Amoxicillin as per PDG. Offer or cloudy, bulging, reassurance that antibiotics are not usually needed retracted or fluid/air because they are likely to make little difference to level seen symptoms improvement. Advise nasal decongestants Visible perforation of Treat with immediate Amoxicillin as per PGD if the tympanic membrane in patient is systemically unwell but does not need association with above referral to medical practitioner symptoms. Treat with immediate Amoxicillin as per PGD if the patient has had symptoms of AOM for more than 4 days and are not improving Treat with immediate Amoxicillin as per PGD for adults and children over 5 years with perforation/discharge due to AOM Ensure all women taking oral contraceptive pill are advised on extra precautions Advise the patient to re-consult GP if symptoms persist despite completing course of antibiotics. Treat pain and fever with paracetamol OR ibuprofen if not contraindicated (OTC or see relevant PGD) Advise on the use of local warmth Advise rest until temperature returns to normal. Increase fluid intake. Advice no flying (swimming or diving) Explain any reduction of hearing may persist for a few weeks after having acute otitis media, follow up is not needed. Patients with penicillin Treat with Erythromycin as per PGD BUT advice that sensitivity the patient defers the start of the course of antibiotics for 24 hours to see if condition resolves. VIRAL EAR INFECTION (CKS, 2009) Mild to moderate pain; Temperature <38o C Coryza; Eardrum may be pink but intact not retracted or bulging. Explain most ear infections resolve spontaneously without the need for antibiotics Analgesia: paracetamol OR ibuprofen if not contraindicated (OTC or see relevant PGD) Advice on the use of local warmth Advice rest until temperature returns to normal Increase fluid intake Avoid smoky atmospheres
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PATIENT FOLLOW UP For patients not treated with antibiotics For patients treated with antibiotics
If symptoms have not resolved after 4 days to return to the MIU or GP If symptoms not resolved after 3-4 days or if symptoms deteriorate then they should contact their General Practitioner or OOH service Patients with perforation Should be followed up by their General Practitioner after 2 weeks. Patients with resolved acute otitis Do not need follow up. Explain reduced hearing media may persist for a few weeks. Patients whose fever, pain or Seek assessment by their General Practitioner or discharge persist over two weeks OOH service Patients with recurrent furuncle Should be followed up by their General (boil) Practitioner The patient demonstrates an understanding of how to manage subsequent episodes of earache.
DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital
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DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital
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ECZEMA PROTOCOL
EXCLUSIONS Nil ASSESSMENT When assessing a patient, you should: Diagnosis is based on the clinical history of lesions, development and examination of the patient. Eczema is classified according to exogenous (external cause) or endogenous (internal cause). The clinical features of eczema relate specifically to the changes in the skin Patients are deemed to be experiencing a form of eczema if they display the features listed below: ATOPIC ECZEMA: An itchy skin condition in the last 12 months and 3 of the following: A history of involvement of skin creases (fronts of elbows, behind knees, fronts of ankles, around neck or eyes) A personal history of asthma/hayfever A history of a generally dry skin in the last year Onset under the age of 2 years Visible flexural eczema Atopic eczema is the most common type of eczema seen in patients. It is a chronic, relapsing inflammatory skin condition. 90% of patches are colonised by Staphylococcal Aureus Changes and Features of Eczema (CKS, 2007) Changes Clinical Features Stages Acute wet, weeping eczema Predominantly epidermal oedema, vesicle formation, dermal vasodilation, extravasation of blood cells, lymphocytic infiltration of epidermis Diminishing oedema. Lymphocytic infiltration, hyperkeratosis, dermal vasodilation and extravasation Predominant epidermal acanthosis, parakeratosis, hyperkeratosis, dermal vasodilation and extravasation Red, inflammed skin. Superficial oedema. Vesicle rupture. Exudate. Pruritus and pain. Irritability and sleep loss. Loss of function. Loss of skin integrity Red/pink inflammation. Vesicle formation/erosions. Crusting drying exudates. Scale formation. Exfoliation. Pruritus. Irritability. Sleep loss. Loss of skin integrity Pink, inflamed skin. Dry, scaling skin. Hyperkeratosis,Lichenification. Pruritus.
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May become infected with bacteria - Staphylococcus Aureus is commonest Inflamed red, itchy skin Weeping skin and pustules and crusts Failure to respond to treatment Rapid worsening of eczema with fever and malaise History of eczema or family member with eczema Itchy red rash in skin creases/bends elbows, behind knees and neck. May affect cheeks in young children. May affect entire surface of the body Skin may feel hot and dry Evidence of scratching (usually caused by exogenous factors) may lead to secondary infection Skin may be wet, weeping, swollen, may be bleeding, oozing and cracking Alteration of skin pigmentation Skin may be dry and thickened (lichenified) Skin will be scaly and cracked Does not affect nappy area
SEBORRHOEIC ECZEMA caused by yeast malarscezia Extremely rare between infancy and puberty Widespread Yellowish scaly crusts in hair occurs on scalp, beard, face and Not sore or itchy body Greasy/moist looking and red especially in Infantile - cradle cap. folds Lesions located in scalp and nappy area initially the spreads to face, neck and armpits POMPHOLYX ECZEMA Very distinctive form of Intense itchy vesicles on sides of fingers and palms of hands eczema that develop rapidly. Sometimes on soles of feet Vesicles contain pearly white fluid that rupture forming yellow crust tinged with dry blood lasting one -two weeks then itching reduces. Bullae may result from several vesicles merging IRRITANT CONTACT DERMATITIS Inflammation of the skin Skin may appear slightly red caused by Mild to severe inflammation contact with external Itching agency. Usually affects Skin blistering/cracking and bleeding at site of contact hands. Chronic: skin dry, inflammed, scaly and thickened
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ALLERGIC CONTACT DERMATITIS a skin reaction that Itchy red rash occurs when the Swelling and blistering immune system reacts Skin may appear thicker, dry and scaly against a specific Reaction usually confined to site of contact and clears when substance (allergen) allergen removed DIFFERENTIAL DIAGNOSIS Other forms of Dermatitis: Stasis dermatitis, Asteatotic dermatitis, Idiopathic dermatitis,
GENERAL MANAGEMENT AND ADVICE Patients with all types of eczema and dermatitis should be advised as below: Discuss with patient to recognise, avoid or reduce exposure to trigger factors i.e. occupational or domestic Remove causative agent e.g. bracelet Swab area if infected, send to the lab. Reception staff to give results to the Nurse practitioner who will record and action (if applicable) in the clinical notes as per documentation protocol
SPECIFIC MANAGEMENT Patients with all types of eczema should be managed as below: Advice patient with chronic eczema to consult community pharmacist re: OTC emollients according to the dryness of the skin and preferences e.g. E45 or Diprobase and apply 23 hourly If flares up treat patients moist/weeping inflammatory skin lesions with OTC topical Corticosteroids Hydrocortisone 1% cream for 7-14 days If flares us treat patients with very dry/scaly inflammatory skin lesions with OTC topical Corticosteroids Hydrocortisone 1% ointment for 7-14 days Advise patients with mild Seborrhoeic Eczema to consult community Pharmacist re: OTC anti-dandruff shampoo containing zinc pyrithione or coal tar preparations. Refer patients with moderate/severe Seborrhoeic Dermatitis to GP Patients with Infected eczema should be managed as below: Treat with Flucloxacillin as per PGD or Erythromycin PGD if allergic to penicillin Swab area and send to lab, report to be recorded in clinical notes as per policy If localised areas of infection may need GP referral for topical antibiotic for 2 weeks If not resolving refer to GP in 7 days
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FOLLOW UP Infected eczema - if the patients symptoms are not settling or worsening after 5-7 days then they should contact their General Practitioner. For patients that require investigations and patch testing refer to their General practitioner Any patient with a first episode of eczema should be followed up be their General Practitioner within two weeks.
DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital
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reassurance as delayed arrhythmias are exceptionally rare and usually preceded by a pre-existing abnormal ECG. Discuss with senior in ED if unsure and until ECG readings can be sent electronically to senior for assessment. Advise the patient that if any symptoms develop to contact own GP within 24 hours or attend the ED.
IMMEDIATE MANAGEMENT OF HIGH VOLTAGE (over 1000 volts) ELECTRIC SHOCK - (Scott, UK health information,2009) Often extensive tissue damage Using clinical judgement and patients signs symptoms - If moderate to severe shock call 9 999 and give ambulance service clinical history, site address and postcode for transfer to ED Record observations: pulse, heart rhythm, BP, RR, pulse oximetry and continue to monitor whilst patient in unit Record 12 lead ECG (2 copies - 1 MIU and 1for transfer) Administer pain relief IF REQUIRED as per pain score and per PGD Do not routinely administer oxygen but monitor saturation levels using pulse oximetry as soon as possible. Only offer supplementary Oxygen as per PGD to patient with SpO2 of less than 94% who are not at risk of hypercapnic respiratory failure aiming for SpO2 of 94-98%. In patients with chronic pulmonary disease who are not at risk of hypercapnic respiratory failure try to maintain a target SpO2 of 8892% until blood gas analysis is available Continually observe ABCDE airway, breathing, circulation, disability and exposure BLS if required If patient is pregnant they will need to be referred for urgent ultrasound scan. Clingfilm to burns or soft yellow paraffin dressing Assess for other injuries Cannulate and flush if nurse practitioner has competency to do so - see Sodium Chloride PGD Contact next of kin if not present Handover to ambulance staff and give a copy of the casualty card with drugs administered and ECG Inform ED of patients transfer for monitoring and management TRANSFER Ensure verbal hand over to paramedics of all treatment/management and medicines given. Ensure a copy of all documentation accompanies the patient with medicines clearly recorded. Ensure patient has an Identification band N.B This protocol is for guidance only: due to the nature and severity of the patients injury some actions/management may be taken out of sequence or done by more than one healthcare professional (registered and/or unregistered) simultaneously. DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital
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EPISTAXIS
90% of nosebleeds occur anteriorly and originate form the nasal septum at the Kiesselbach plexus (Little's area). Posterior bleeding emulates from deeper structures of the nose and occurs more commonly in the elderly and may be potentially very serious. The causes are many (most cases do not have an identifiable cause) and may include: Local Trauma - Picking nose, facial trauma, foreign bodies Hypertension - rarely a cause but associated with epistaxis Blowing nose too hard Upper Respiratory Tract Infection particularly in children Medications - anticoagulants Vascular abnormalities or inherited coagulopathies EXCLUSIONS Patients with newly diagnosed hypertension Patients taking anticoagulants or have inherited coagulopathies Patients with massive epistaxis These patients must be referred to a doctor once immediate treatment has been given. ASSESSMENT When assessing a patient you should: Check and record blood pressure Assess ABC and manage as required Assess blood loss (if blood loss is severe refer to Plymouth Hospital Trust A+ED) MANAGEMENT AND DISCHARGE PLAN Patients with epistaxis should be managed as below: Gently insert nasal speculum and spread the naris vertically to view the anterior septum area. Aim to arrest bleeding: Sit patient forward and advise the patient to pinch the entire nose (Little's area), against the nasal septum - maintaining continuous pressure for 10 - 20 minutes Apply ice pack to bridge of nose Insert nasal tampon dressing in nostril, for 15 - 20 minutes. Observe the patient for a while (use clinical judgement) after the bleeding has stopped Check observations Advice patients not to blow their nose or swallow blood that runs down the throat If bleeding stops and patient has support at home discharge patient with letter to GP If bleeding is does not stop or is severe refer to on call ENT (ear, nose and throat) surgeon via switchboard at Plymouth Hospital Trust. If patient is hypertensive refer to GP DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital
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Record and document Blood Pressure reading Document the reason for request for emergency contraception. Discuss and document all episodes of UPSI in the current cycle Emergency contraception is indicated whenever there is a risk of unwanted conception e.g. unprotected intercourse, split condom, forgotten pills, extended pill-free interval, after rape or sexual assault, when withdrawal methods have been used, or after ejaculation onto the external genitalia. See table below as agreed with PCH CC&SH service manager. Comment Emergency Contraception Emergency Hormonal Method Hormonal Contraception Not Contraception Indicated Indicated Up to 2 pills missed Whether emergency Combined oral 3 or more pills missed from from anywhere in the contraception is indicated contraceptive anywhere in the pack or not, continue the COC pills (COC) pack as below and also use a (30mcgs barrier method until Estrogen or consecutive pills taken. more) If pills are missed in the first 7 days, and also in previous pack treat as 3 or more. If less than 7 pills remain, finish pack and begin new one immediately forget about pill free interval. Take the last pill missed NOW and take the rest of the pack as usual. 1 pill missed from Continue the COC to end 2 or more pills Combined oral are missed from anywhere in the pack of pack and use a barrier contraceptive method for 7 days, anywhere in the pills (COC) whether emergency pack 20mcgs contraception indicated or Estrogen not As Above Excluded from MIU PGD if sexual Enzyme as potential drug intercourse Induces interaction Refer to GP occurs whilst or CC&SH taking COCs concurrently with Enzyme Inducing drugs Condoms Rupture or dislodgment during intercourse Diaphragm Inserted
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and Cap
incorrectly, torn/dislodged during intercourse, removed too early Patch off for longer than 48 hours
1 or more pills missed or taken more than 3 hours late ( Cerazette POP only 12 hours late), and unprotected sex occurred within 2 days after a missed or late pill If UPSI within 7 days after insertion of implant, if insertion occurred after day 5 of their menstrual cycle. If UPSI within 28 days after the use of liver enzyme-inducers unless additional barrier method has been used Intercourse following expiration of implant (3 years
Pill taken less than 3 hours late Less than 12 hours late for Cerazette
If the patch has been off for less than 48 hours apply a new patch and change it on your normal change day. If the patch has been off for more than 48 hours, start a new patch cycle. Apply a new patch and treat as week 1. Use a barrier method for the first 7 days of the new cycle. Where emergency contraception indicated, continue the POP and use a barrier method until pills have been taken correctly for 2 consecutive days
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after insertion) Injection is more Injection is up to 2 than 2 weeks weeks overdue overdue (i.e. 14 weeks after last injection) and the first episode of unprotected sex has occurred within the previous 72 hours Complete or partial expulsion
Where emergency contraception is not indicated, Depo-Provera can be given and no additional barrier method required refer patient to GP or CC&SH service
Emergency contraception can be used up to 72 hours after sex; refer to GP or CC&SH service for replacement IUS/IUD
Document Last Menstrual Period and verify that this was a 'normal' period. There is no day of the menstrual cycle when there can be certainty that unprotected sex would not result in pregnancy. If NP suspect that patient Do a pregnancy test may already be pregnant Refer patient to her GP or CC&SH Service Explain that emergency contraception cannot be given to patients that are already pregnant Discuss and document risk of sexually acquired infections and Chlamydia. Chlamydia screening should be offered to all sexually active patients - see screening for Chlamydia policy. Discuss the need for future contraception and provide details of access to services. If the patient falls outside of the protocol during the assessment the casualty card must show the full consultation and the decision making process. Supply Levonorgestrel in accordance with PGD. Levonorgestrel should be given as a directly-observed treatment. Advice the patient: That Emergency Hormonal Contraception is to be taken within 72 hours of an act of unprotected sexual intercourse (UPSI). When taken within 24 hours of UPSI, it is 95% effective and the effectiveness reduces to 58% efficacy at 72 hours. See table below. Time contraception taken after Proportion of pregnancies prevented intercourse 24 hours 95% 25-48 hours 85% 49-72 hours 58% That if vomiting occurs within 2 hours of taking Levonorgestrel they will need to repeat the treatment
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If the patient's next period is more than 5 days late they should carry out a pregnancy test N.B In all cases, the use of Emergency Intra-uterine device (can be fitted up to day 5 of UPSI or up to day 19 of a 28 day cycle) is more effective than Emergency Hormonal Contraception (EHC). All patients requesting EHC should be offered emergency IUD additionally Refer to CC&SH Service (Monday - Friday) or GP for fitting. DISCHARGE PLAN Contraception advice for the remainder of the cycle has been discussed with the patient The patient knows where to seek advice for further protection, Chlamydia screening and CC&SH advice.
DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital
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MANAGEMENT Patients with foreign bodies in the nose should be managed as below: The patient should be positioned in a clear, bright light or lying down on examination couch. Only attempt to remove visible foreign bodies from the nose if they can be easily visualised, grasped and can be removed without causing injury. Explain the procedure to the patient and obtain consent for removal. The foreign body should be removed using appropriate methods only by those trained and competent in the procedures: 1. Blow nostril or mouth with patent nostril closed - parents can do this. 2. Suction using a fine suction catheter held in contact with the object is sometimes a useful method of removal 3. Use a blunt hook, crocodile or fine forceps. Place instrument behind the object and pull out or grasp object and remove. Do not push and avoid any interventions that may push the FB deeper into nose as this can cause damage to deeper structures. If the foreign body moves away from forceps STOP - refer to ENT department PHT The foreign body should be inspected when removed to ensure that it is intact. (If not intact liaise with ENT PHT) The foreign body should be removed with the appropriate forceps. Use thudicums speculum and a blunt hook, crocodile or fine toothed forceps The foreign body should be carefully inspected to make sure that it is intact. (If not intact liaise with ENT DGH)
DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital The examination and removal of a foreign body should be documented on the casualty card.
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MANAGEMENT OF SPECIFIC FRACTURES MANAGEMENT OF UPPER LIMB FRACTURES Patients with specific upper limb fractures should be managed as below: 1ST MC Significant angulation, Dislocation and (or) Fracture involving the joint # not involving joint 5th MC 5th MC Neck - Displaced/severely angulated (lateral xray to measure) > 50 degrees or any rotation on clinical examination Un-displaced or minor angulation 5th MC Shaft - >40 angulation 5th MC Base Refer to Plastics SHO via switchboard Bennetts POP and check x-ray Refer to Plastics SHO via switchboard
Discuss X-ray with ED 37777 then select option 4 for advice or refer to Plastics SHO Neighbour strapping and sling if swollen Finger exercise MIU follow up (or Clinic One) Discuss X-ray with ED as above Refer to Plastics SHO as above
OTHER MC Displaced/complicated/multiple/angulated Refer to Plastics SHO >30 Base of MC involving CMC joint Futura splint & refer to Plastics Un-displaced or minor angulation Buddy strapping and sling if swollen Finger exercise MIU or Clinic One follow up AMPUTATIONS TO DIGITS Assess injury Assess bleeding and manage accordingly - saline pressure dressing Wrap amputated digit in saline and place in bag Analgesia according to pain score Refer to ED or refer to Plastic SHO as above ALL PHALANX # TO INDEX, MIDDLE, RING, LITTLE DIGITS Check for rotation deformity and overlap Angulated transverse fractures of the Proximal Phalanx may be very disabling, if in doubt refer to ED for assessment Check base of little finger Proximal Phalanx carefully, may be difficult to see angulation If PIPJ swollen and concerned ?boutonniere review patient in MIU 2/3 days Displaced/angulated, comminuted Refer to ED Senior or Plastics Hand Clinic (mulitfragmentary)
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Un-displaced
Digit Phalanx -Buddy strapping Thumb Phalanx Elastoplast thumb spica. If laxity at 1st MCPJ - Refer to Plastic SHO Finger exercise MIU follow up Neighbour strapping 3-4 days Advice OTC or supply analgesia for pain relief Refer to MIU or Clinic 1 for follow up Refer to Plastic SHO as above
FRACTURES OF DISTAL PHALANX Undisplaced/closed Consider Trephine if subungual haematoma Mallet Splint Refer to MIU or Clinic 1 for follow up Displaced/compound # Ring Block and manipulate if required Trephine if subungual haematoma collection (not if draining) Replace nail under nail fold if necessary but do not remove nail unless absolutely necessary Supply Flucloxacillin as per PGD Mallet Splint Refer to MIU or Clinic 1 for follow up unless reconstruction required, in which case refer direct to Plastics SHO DISLOCATIONS OF PROXIMAL AND DISTAL INTERPHARANGEAL JOINTS Check the history of injury fits with a dislocation Check circulation of the digit, if in doubt refer to a doctor for assessment Check the nerves distal to the dislocation. Uncomplicated dislocations Check tendon and nerve function X-ray to confirm diagnosis Explain procedure to patient and gain consent. Ring block with Local Anaesthetic Lidocaine as per PGD Relocate joint Check movement/circulation Check tendon and nerve function Neighbour Strapping Check X-ray MIU follow up (or Clinic One) Compound dislocations or Signs of Refer to ED or Plastics SHO as above a fracture with dislocation WRIST No bony injury
Un-displaced fracture
Treat pain according to pain score or swelling with OTC or analgesia as per PGD Consider supportive bandage with or without sling. Consider futura splint if severe pain or dysfunction POP backslab, Broad arm sling, Next available Fracture clinic, Instruction sheet regarding care of plaster
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Splint/sling, POP backslab. Liaise with ED (37777 (option 4) for advice and discuss whether transfer needed for immediate treatment. Transfer as per documentation protocol and X-ray/NHS number recorded clearly on notes, nil by mouth if for immediate manipulation
SCAPHOID Fracture may not show on initial x-ray. History may be of a fall onto outstretched hand or a starting handle type injury. If the mechanism of injury and the clinical signs suggest a possible fracture of the Scaphoid ALWAYS treat as for a fractured Scaphoid. Clinical signs include: Specific tenderness and/or swelling in the anatomical snuffbox Specific tenderness over the Scaphoid tubercle Pain on telescoping the thumb Very poor grip Reduced wrist movement MANAGEMENT: For confirmed fracture on initial xray - full forearm P.O.P unless wrist is very swollen (then use backslab) and instructions. High arm sling 24 hours, analgesia as required and referral to next available Fracture clinic For 'clinical' suspected fractures: Futura Splint or Full forearm POP and instructions for clinically fractured but no fracture on xray, High arm sling (if very swollen), analgesia as required and referral to MIU or Clinic 1 in 10-14 days (NOT BEFORE) SHAFT RADIUS AND ULNA No bony injury Supportive bandage, with or without sling Follow up at GPs surgery if necessary. Un-displaced fracture Long arm P.O.P, check xray, sling Next available Fracture clinic, Instructions regarding care of plaster. OTC Analgesia or as per PGD as per pain score Displaced fracture BAS or Full arm splint depending on pain score Liaise with ED as above re: transfer with documentation and X-rays, nil by mouth. ISOLATED FRACTURE MIDSHAFT OF EITHER RADIUS AND ULNA NB. An isolated mid-shaft fracture of one of forearm bones (except transverse mid shaft Ulna)(Defence fracture) with other intact suggests Radio-ulnar joint dislocation. It is essential that x-rays include the joints above and below the injury. MONTEGGIA- Dislocation radial head with fracture ulna GALEAZZI- Fracture radius with dislocation inferior radio-ulnar joint Undisplaced fracture Long arm P.O.P, check xray, sling with no obvious Next available Fracture clinic, persistent dislocation Instructions regarding care of plaster. OTC Analgesia or as per PGD as per pain score Displaced fracture or BAS or Full arm splint depending on pain score definite dislocation Liaise with ED as above re: transfer with documentation and X-rays nil by mouth.
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RADIAL HEAD/NECK Un-displaced Severe/dislocated Elbow injuries with radiological evidence of a effusion but no fracture anterior or posterior fat pad sign
Collar & cuff OTC Analgesia or as per PGD as per pain score Next available Fracture clinic Refer to Orthopaedics Collar and Cuff OTC Analgesia or as per PGD as per pain score Clinic 1, MIU clinic as appropriate
SUPRACONDYLAR, CONDYLE OR EPICONDYLE - Beware Epicondylar fractures in children Displaced or dislocated Check radial pulse if absent, gentle traction may restore Refer to ED as above Un-displaced Above Elbow backslab POP Collar & cuff Next available Fracture clinic Beware of compartment syndrome especially in children with displaced fracture. Beware anterior nerve (median/ulna) and vessel (brachial artery) damage OLECRANON Displaced Un-displaced
Refer to ED as above Long arm pop & sling Next available Fracture clinic
Manipulate - should go back with an audible 'click' Wait 5-15 minutes If child using the elbow reassure and discharge If the child is not using the elbow consider xray if doubt about diagnosis. Otherwise collar and cuff and review in MIU the next day.
ALL ELBOW INJURIES ARE TREATED IN COLLAR & CUFF NOT A BROAD ARM SLING.
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SHOULDER INJURIES. See APPENDIX J - ADVICE LEAFLETS FOR SHOULDER MANAGEMENT Ascertain:-How they fell - onto outstretched hand or direct blow/fall onto the front, back or point of shoulder. If no history of injury or trauma - consider soft tissue/joint inflammation are the most common causes but there are other causes if pain is point of shoulder e.g. diaphragmatic irritation from? appendicitis, gallbladder disease or ectopic pregnancy. Carpal tunnel syndrome, Anterior Myocardial Infarction, lung problems or cervical spondylosis/spine problems Examination (remember to look from the front, behind and above) :- look for contour and symmetry (remember bilateral dislocations do occur especially posteriors during fits and will look symmetrical), deformity, swelling, inflammation, erythema, or muscle wasting Normal shoulder movement in degrees: flexion 0-180, extension 0- 45, abduction 0-170, internal and external rotation 0- 70 - remember to differentiate between scapular rotation and glenohumeral movement Anterior Dislocation: - 95%. squared off appearance due to loss of deltoid bulge, arm slightly abducted, and elbow at lower level. May damage axillary nerve. Posterior Dislocation: - 5%. only uncommon, easily missed, most due to trauma but may have a history of fit or electric shock, fixed internal rotation Inferior Dislocation:- rare, high incidence of vascular and nerve injury Check for arterial and nerve injury Shoulder injury exclusions Refer to ED patients with:from management in MIU Dislocations or history of dislocation that has spontaneously reduced o Glenohumeral joint Posterior Anterior o Sternoclavicular joint posterior Patients with any artery or nerve injury related to fracture/dislocation Fractured Glenoid Clavicle o Open fracture o Tented or threatened skin o Involving SCJ Children under 16 with suspected fracture/dislocation to shoulder joint HEAD/NECKOF HUMERUS/GREATER TUBEROSITY - fall onto the shoulder or outstretched hand Un-displaced Test radial nerve - usually impossible to damage with undisplaced fracture, more likely with shaft fracture. Collar and cuff Analgesia as per PGD Next available Fracture clinic Displaced/Comminuted Collar and cuff Refer to hospital Orthopaedics or ED Senior 37777 ext 4 SHAFT OF HUMERUS - usually elderly, pathological fractures common, NAI These fracture can cause radial nerve injury/problems No bony injury Collar and Cuff if necessary, early mobilisation
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Fracture
Displaced
Check for damage to the radial nerve (wrist dorisflexion) radial artery and elbow joint Collar and Cuff Next available Fracture clinic Check for damage to the radial nerve (wrist dorisflexion) radial artery and elbow joint. If normal Discuss xray with ED Senior 37777 ext 4 Collar and Cuff and Next available Fracture clinic, if absent refer to hospital ED
CLAVICLE - fall onto outstretched hand or direct blow No bony injury Check brachial plexus Be aware of subclavian vessel injury Broad arm sling if necessary, early mobilisation Undisplaced Fracture Check brachial plexus Broad arm sling Next available Fracture clinic Displaced Check for possible pneumothorax - if present to ED. Check pulse/nerve function. If normal BAS and Next available Fracture clinic, if absent refer to hospital ED If tenting refer to orthopaedic SHO AC JOINT DISRUPTION - fall or rolling fall onto shoulder Local tenderness and swelling with prominence of the outer end of the clavicle. Stability depends on conoid and trapezoid ligaments AP Xray Interpretation - the width of a normal AC joint is less than 10 mm and the lower borders of the acromion and the clavicle should be in line. Subluxation is seen as a step between them. Grade 1:- minimal separation, only the ac ligaments involved Grade 2:- obvious subluxation - if clavicle half way up acromion process Grade 3/4:- if the clavicle is level with or higher than the acromion process Conservative management Grade 1/2 Broad Arm Sling Conoid and Trapezoid Analgesia as per PGD ligaments intact Advice to mobilise GP Follow up 7 days Broad Arm Sling Grade 3/4 Analgesia as per PGD Conoid and Trapezoid Advice to mobilise ligaments ruptured Next available Fracture Clinic ? surgery SCAPULA - Usually high impact Trauma, often associated with chest injuries Sites:- blade, neck, coracoid, acromion No Bony Injury Broad arm sling Analgesia as per PGD Mobilise To GP Fracture of body or neck Refer to ED/Orthopaedics
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GLENOID LABRIUM CARTILAGE TEAR - are very difficult to diagnose in a patient with significant post traumatic symptoms Acute pain but able to move If suspected clinically refer to MIU Clinic
Shoulder X-ray - For acute injury only and for patients with any of the following : 1. Age 16 years or older 2. Suspected fracture to scapula, (SC joint, clavicle, AC joint), greater tuberosity, head humerus 3. Injury is not more than 14 days old 4. For injuries around the clavicle that are well localised -consider clavicle or ACJ views X-RAY INTERPRETATION AP look for changes in contour, breaks and steps in bony cortex. The humeral head should appear asymmetrical with the greater tuberosity obvious. The humeral head and glenoid should be conguious. Modified Axial or Lateral Scapula Y view (not both) - will show posterior dislocation humeral head, # corcoid process, cortical # of the anterior or posterior humeral head and glenoid fossa If unable to get Modified Axial a Y view must be obtained Weight bearing xrays may be required for ACJ Contact ED for senior advise on x-ray interpretation if required 37777 - ext 4 NON TRAUMA SHOULDER PAIN If no history of injury or trauma consider Soft tissue inflammatory conditions: Tendonitis Acute calcific periarthritis (severe pain) Arthritis and arthropathy Other rare causes of referred pain Neck problems Diaphragmatic irritation Anterior myocardial infarction Conservative management for 3 weeks Reassurance Analgesia advice or NSAID's Ice Teach shoulder exercises Early referral to Physio for elderly Physio if no improvement Current shoulder advice leaflet See own GP if no improvement
SUSPECTED SOFT TISSUE INJURIES AND PROBLEMS AROUND THE SHOULDER Conservative management for 3 weeks Rotator cuff tendonitis - caused by Reassurance sudden traction to shoulder, may be Analgesia advice or NSAID's chronic Ice limited movement, night pain and Teach shoulder exercises muscle weakness Early referral to Physio for elderly Rotator cuff tears - caused by chronic tendonitis, spontaneously or following a Physio if no improvement Current shoulder advice leaflet fall - usually supraspinatus and See own GP if no improvement infraspinatus. Tenderness over cuff insertions and For Supraspinatus injuries: subcromial area. 1. Supraspinatus - Test for trick refer to Derriford ED movements in abduction and lack of ability to initiate abduction. If cannot
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abduct supraspinatus, painful arc Frozen shoulder - Usually gradual onset of pain, marked pain on shoulder and reduced range of movement. Associated with rotor cuff degeneration, minor trauma or prolonged immobilisation. Ruptured biceps tendon/tendonitis ruptures through degenerate tendon. Impingement and pain over bicep area caused by sudden muscular effort. In complete tears may be a palpable bulge to biceps on contracting muscle. Head of biceps tears which are the shoulder ones do not always result in bunching (because two heads and rarely complete). Bunching upwards on using biceps suggests tendon injury at elbow. Bunching downwards, complete long head tear Acute calcific tendonitis - Calcium may be deposited within the rotor cuff tendon as a result of degenerative changes or minor trauma. Usually acute inflammatory episodes with severe pain, swelling and warmth of the shoulder which may mimic gout or infection. Bursitis - usually caused from overuse from repetitive use of the shoulder leading to micro-trauma Should also specifically mention sub acromial impingement rather than just bursitis. Empty can and other tests in examination Arthritis/degenerative joint disease Usually chronic condition with a history of previous shoulder problems. May have effusion, erythema and warmth
SUB ACROMIAL IMPINGEMENT (Painful Arc Syndrome) The gap between the acromion and head of humerus is relatively small. Anything which causes further narrowing of the gap, or swelling of the structures within the gap may cause pain particularly on abduction Causes include: osteoarthritis of ACJ with osteophytes bursitis supraspinatus tendonitis (acute/chronic) Muscle spasm pulling humerus upwards
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Signs and symptoms: Tenderness around acromion Painful arc in abduction Specific impingement tests positive empty can test
NSAI or other analgesia if unable to take Advise gentle mobilisation Refer to MIU Clinic if not settling
ALL PAEDIATRIC EPIPHYSEAL INJURIES TO UPPER LIMB Type 1 - V Salter Harris epiphyseal injuries and all must be reviewed in some capacity Epiphyseal fractures to upper limb Undisplaced -Treat as per fracture management SH11 fracture and buckle fractures to upper and neck of humerus are common TENDON INJURIES TO UPPER LIMB MALLET FINGER Check tendon and nerve function Always x-ray Mallet splint and instructions. (Inform patient splint will be insitu for at least 8 weeks) If the patient has delayed presentation inform them that repair of tendon may be compromised MIU NP or Clinic One for follow up about 7-14 days then 6 week MIU Clinic appointment Collar and Cuff Fracture clinic If Type 111 - V refer to ED for advice as above
BOUTONNIERE DEFORMITY - sudden forced flexion or knife/glass causing laceration/tear to the middle slip of the extensor tendon at the PIPJ Always x-ray Check tendon and nerve function If closed injury - Boutonniere splint and instructions. Refer to Hand clinic/MIU follow up If open injury refer to Plastics SHO via switchboard MANAGEMENT OF SOME NON TRAUMATIC UPPER LIMB PROBLEMS NON TRAUMATIC UPPER LIMB PROBLEMS Instruction why happens Trigger Finger/Thumb Advice to use Tender nodule over Refer to GP for referral to PHT tendon and MCPJ clicks on flexion Futura splint Carpal Tunnel Refer to GP Compression of median nerve at wrist Dequervains Instruction why happens Tenovaginitis Advice to use Thickening of tendon Refer to GP sheath of long abductor and short extensor tendons of thumb
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Tennis or Golfers elbow medial and lateral epicondylitis Non-infected Olecranon bursitis
If history very recent consider referral to GP for ?Physiotherapy Refer to GP OTC or supply Ibuprofen if not contraindicated If large or recurrent refer to ED for consideration of aspiration (if very large or multiple recurrences only). If small tubigrip Ice area ++++ OTC or supply Ibuprofen if not contraindicated Follow up GP Refer to ED/GP OTC or supply analgesia as required Tubigrip Broad arm sling Ice +++
MANAGEMENT OF LOWER LIMB FRACTURES Patient with specific Lower limb fractures should be managed as below: FRACTURE NECK OF FEMUR Requires Orthopaedic admission Analgesia & refer to hospital by ambulance. If competent cannulate and Sodium Chloride 0.9% injection as per PGD. Obtain ECG and observations if time permits FRACTURE SHAFT OF FEMUR Requires Orthopaedic admission Refer to hospital by ambulance Analgesia in accordance with pain score and appropriate analgesia PGD Baseline observations If competent cannulate if possible and Sodium Chloride 0.9% injection as per PGD Donway splint (Supplied by Ambulance) SIGNIFICANT AVULSION FRACTURE TIBIAL SPINE (indicates cruciate ligament injury) Refer to ED Analgesia in accordance with pain score and appropriate analgesia PGD FRACTURE/DISLOCATION OF PATELLA If competent relocate patella if not already done by patient Refer to ED Analgesia in accordance with pain score and appropriate analgesia PGD
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OSTEOCHONDRAL FRACTURES Requires Orthopaedic Discuss with ED as above Admission if severe Analgesia in accordance with pain score and appropriate analgesia PGD Long Leg Backslab POP KNEE INJURIES Ascertain:-Time of injury, mechanism (exact if possible to include whether foot was fixed, the degree of and direction of force applied to the knee), presence and timing of swelling, ability to weight bear immediately and now, previous knee problems, any locking, giving way and site of maximum pain. Examination with knee extended Inspect knee for bruising, swelling, redness, deformity Palpate for effusion, tenderness and continuity of extensor mechanism. Patella tap, Quadriceps function inhibited by pain, unable to straight leg raise, palpable gaps in patellar function, is patella in groove Flex knee as close to 90 degrees as tolerated, palpate joint lines and over collateral ligaments, palpate tibial tubercles and femoral condyles Test specific ligament stability lateral and medial collateral ligaments test in extension and 15 degrees flexion. Test cruciates with anterior draw test ? lachmanns Active range of movements Ability to weight bear Knee exclusions from Refer to ED patients with:Management in MIU Haemarthosis Locked knee Clinically unstable knee Dislocated Patella or history of Unable to straight leg raise Proven fracture on x-ray Analgesia as required according to pain score Crutches Advise elevation to reduce swelling Suspected Ligament or Ice if appropriate Meniscus injury without Teach quadriceps exercises to be carried out 2 x a day instability or other Crutches if unable to weight bear and encourage to take mechanical symptoms weight Analgesia advise as required Follow up: If patient needs crutches, has an effusion or in whom clear examination is not possible due to pain refer to Clinic 1 or MIU clinic for consultant review. Other patients should be advised to seek further assessment at their GP or ED if not settling well in 1 -2 weeks N.B The need to X-ray a knee injury should be assessed using the Ottawa knee rules as below: Knee X-ray in acute injury are required only for patients with any of the following : 5. Age 55 years or older
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6. Isolated tenderness of the patella (no bone tenderness of the knee other than the patella) 7. Tenderness at the head of the fibula 8. Inability to flex the knee to 90 degrees 9. Inability to bear weight both immediately and in the MIU (4 steps - unable to transfer weight twice onto each lower limb regardless of limping) X-RAY INTERPRETATION AP look for changes in contour, breaks and steps in bony cortex. Check for avulsion fractures close to tibial spines. Look for fractures and position of patella Lateral Should be taken as horizontal beam lateral. Look for effusion and lipohaemarthrosis which suggests fracture Check patella Does tibia appear to have slipped backwards on femur (posterior cruciate) Check contours and for breaks in cortex Contact ED for senior advise on x-ray interpretation if required 37777 - 4 FRACTURE OF TIBIAL PLATEAU Discuss with senior in ED as above Analgesia in accordance with pain score and appropriate analgesia PGD l Long Leg Backslab POP ISOLATED FRACTURE UPPER OR MIDSHAFT FIBULA Examine lateral popliteal nerve Discuss with senior in ED Analgesia in accordance with pain score and appropriate analgesia PGD Treat with tubigrip or POP if severe pain If POP carry out Venous Thromb-embolism Risk Assessment for adults. Refer to next available Fracture Clinic FRACTURED SHAFT TIBIA AND FIBULA Undisplaced Long Leg POP - carry out Venous Thrombembolism Risk Assessment for adults Re X-ray to check position Refer to ED as above Children If under 1 year or non weight bearing refer to Paediatrics. Children under 2 years excluded from xray protocol. Older children non-weight bearing on crutches. Refer to next available fracture clinic Displaced Immobilise in backslab carry out Venous Thromb-embolism Risk Assessment for adults Analgesia in accordance with pain score and appropriate analgesia PGD Refer to ED as above
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Fractures with severe soft tissue injury STRESS FRACTURE Can occur in tibia or fibula. Sudden onset pain with no real mechanism of injury may have excessive exercise/training. Tenderness over the bone and pain on stressing
If positive xray Below knee POP - carry out Venous Thromb-embolism Risk Assessment for adults Crutches Analgesia in accordance with pain score and appropriate analgesia PGD Refer to next available fracture clinic May need appointment for NP review in two weeks if no initial clinical indication to xray.
TODDLERS FRACTURE A toddler who falls and who will not weight bear must have the whole limb xrayed unless clinical examination can localise an injured area. Spiral fractures of the tibia may not be visible on initial xrays. Remember that if they can crawl, the injury is likely to be below the knee
If the child will not weight bear and x-rays are normal long leg POP Analgesia in accordance with pain score and appropriate analgesia PGD Refer to next available fracture clinic or paediatric ED clinic
MANAGEMENT OF THE LIMPING CHILD Depends on history, assessment and Refer to ED for advice as above examination findings. Follow 'Management of the Limping Child' - Fordham/Higgi Sept 2009 PHT ANKLE INJURIES No bony injury - simple sprain
Double tubigrip or Crepe if clinical decision requires due to swelling. Advice RICE and supportive shoes Follow up GP/Physio if required (unable to weight bear without crutches) Un-displaced fracture Below knee P.O.P carry out Venous Thrombembolism Risk Assessment for adults Pop instructions Crutches (NWB) Next available Fracture clinic Displaced fracture Seek advice from ED as above A SEVERELY DISPLACED FRACTURE THAT POSES A RISK OF NEUROVASCULAR DEFICIT OR SKIN DAMAGE SHOULD BE REDUCED IMMEDIATELY AND PRIOR TO TRANSFER TO HOSPITAL.
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The need to X-ray an ankle injury should be assessed using the 'Ottawa ankle rules' see below: Ankle X-ray is required only if there is:1. Tenderness upon palpation of distal 6cms of posterior edge and tip of lateral and/or medial malleolus. 2. Inability to weight bear immediately after injury and/or in the department (4 steps) 3. Age over 55 Requires Orthopaedic admission-refer to hospital Bilateral fractures
CALCANEUM # Calcaneum
Wool & crepe Crutches Analgesia in accordance with pain score and appropriate analgesia PGD Advice/elevation Discuss with ED Senior (May also require admission for elevation) Next available Fracture clinic Requires Orthopaedic admission-refer to hospital
FRACTURE BASE 5TH METATARSAL For avulsion fractures which can produce big fragments: Symptomatic treatment, usually crepe/DTG but if severe pain Below Knee POP & crutches - carry out Venous Thrombembolism Risk Assessment for adults Refer next available fracture clinic. Remember that the Jones fracture of the proximal metatarsal shaft is more serious. OTHER FRACTURED METATARSALS Displaced/multiple Discuss with ED Senior as above, may require admission Un-displaced Symptomatic treatment as above
METATARSAL STRESS FRACTURE Can occur in metatarsals. Sudden onset pain with no real mechanism of injury may have excessive exercise/training. Tenderness over the bone and pain on stressing
Often no evidence of a fracture on initial x-ray therefore advise the patient of this. Review in two weeks (by appointment) and xray foot Analgesia in accordance with pain score and appropriate analgesia PGD Refer to next available fracture clinic if fracture when x-rayed either initially or at two weeks Refer A+ED Senior as above
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The need to X-ray a foot injury following an inversion injury should be assessed using the 'Ottowa ankle rules' see below: Remember that other parts of the foot may be injured in different mechanisms. The Ottowa rules apply to inversion injuries. Foot X-ray is required only if there is any pain in the midfoot area and any of the following: 1. Tenderness upon palpation at the base of 5th MT and/or medial aspect of navicular. 2. Inabilities to weight bear, both immediately after injury and in the department (4 steps) 3. Age over 55 ALL PHALANGES # TO GREAT, 2nd, 3rd, 4th AND 5th TOES Amputated Toes - manage as per amputated digits No bony injury Two toe strapping if required Advise supportive sensible footwear and advice OTC analgesia Un-displaced fracture Two toe strapping Advice OTC analgesia Advise supportive sensible footwear Refer GP Displaced fracture Liaise with ED
DISLOCATIONS TO PROXIMAL OR DISTAL INTERPHARAGEL JOINTS-TOES Check the history of injury fits with a dislocation Check circulation of the digit, if in doubt refer to a doctor for assessment Check the nerves distal to the dislocation. Uncomplicated dislocations X-ray to confirm diagnosis Explain procedure to patient and gain consent. Ring block with Local Anaesthetic - Lidocaine as per PGD Relocate joint Check movement/circulation Buddy Strapping Check X-ray MIU Clinic (or Clinic One) Signs of a fracture with Refer to ED or Ortho SHO dislocation EPIPHYSEAL INJURIES IN CHILDREN Epiphyseal fractures lower limb Seek advice form ED as above
QUADRICEPS HAEMATOMA Trauma - fall Able to fully weight bear, not abnormal findings - bony tenderness, loss of muscle, tendon or nerve function
Advice ice +++ Elevate limb Crutches Analgesia in accordance with pain score and appropriate analgesia OTC or as per PGD Refer to GP or Clinic 1
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TENDON INJURIES TO LOWER LIMB ACHILLES TENDON (RUPTURED) Very sudden pain in lower calf may occur spontaneously, and/or History of injury with sudden pain in lower calf. May be missed because of pain and swelling at the time of injury and foot can be plantar flexed by the long toe flexors Signs of rupture include Palpable gap in Tendon or Inability to stand on tiptoe on the affected foot or Positive squeeze Test (Simmonds Test) See Calf Injury Protocol for Gastrocnemius and Soleus injuries
MANAGEMENT OF SOME NON TRAUMATIC LOWER LIMB PROBLEMS NON TRAUMATIC LOWER LIMB PROBLEMS Osgood Schlatters Disease Advise as to the nature of the disease Advise rest when pain acute Advice exercise when pain better Tubigrip if applicable Advice OTC Analgesia as required Refer to GP for follow up in 3-7 days If large or recurrent refer to MIU Clinic or Clinic 1 If small use clinical judgement ?tubigrip Ice area ++++ Advice OTC Ibuprofen if not contraindicated Follow up GP or Clinic 1 Advice patient on correct foot wear Ice area Advice OTC Ibuprofen if not contraindicated Rest when pain acute Crutches if acute pain on presentation Refer to GP 7 days Complete recovery can take a year. Wear shoes with good arch support and cushioned heels Give patient initially a horseshoe shaped pad of orthopaedic felt to take weight off painful area - heel raise Rest foot Advise exercises to stretch calf muscles Refer to GP 7-14 days Advise OTC Ibuprofen if not contraindicated
Pre-patellar/Infra-patellar Bursistis
Shin Splints
Plantar Fasciitis
DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital
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PATIENTS WITH A # NOSE - (CKS, 2009 and PHT ENT Consultant) Refer to Maxillofacial OPD via secretary (Linda Deviation Cornish) 763220 and send/fax copy clinical notes Epistaxis at time of injury Advise patient length of time until appointment No Septal haematoma Septum deviated Advice OTC or supply analgesia as per PGD Able to breathe from each nostril Advice patient not to blow or pick nose Advice patient to see GP if any smelly discharge
PATIENTS WITH A SOFT TISSUE INJURY- (CKS, 2009 and PHT ENT Consultant) Advice OTC or supply analgesia as per PGD No deviation No epistaxis at time of injury/since Advice patient not to blow or pick nose No Septal haematoma Septum midline Advice patient to see own GP in 5-7 days if any Able to breathe from concerns each nostril Advice patient to see GP if any smelly discharge Detecting Septal Dislocation Septal dislocation can cause deviation of the form of the nose and may partially or completely obstruct the airway. A dislocated septum (cartilage) occurs when trauma causes the septum to jump out from the groove lying in the midline of the floor of the nose. To most easily see this look at the skin dividing the nose into the two nostrils (the columella) and look to see if the septum is moved to one side of it. Gentle pressure applied to the columella will make the septum move further into the airway. DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital Write and send routine letter of patient's attendance and treatment to GP. Children under 5 years must have a Health Visitor referral. All other discharge plans as per clinical decision by the nurse practitioner. No need to follow up routinely If symptoms not resolved within 7 days or are worsening to contact own General Practitioner
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RINGWORM OF THE SKIN - (CKS, 2007) tinea corporis Begins typically as a single scaly circular erythematous plague with slightly raised border May be inflammed May have papule or pustules at border As inflammation clears the lesion may appear as a ring or several rings GROIN INFECTION - (CKS, 2007) tinea cruris or jock Scaly erythematous lesions on the medial aspect of the thighs and itch in the inguinal folds Often bilateral and may spread to natal cleft but not genitals
REFFERRAL PATHWAY Patients with fungal infections outside the protocols should be referred as below: SCALP RINGWORM - (CKS, 2007) tinea capitis Inflammation and scaling in scalp Human Origin If severe: Boggy, oozing, tender, localised swelling, fever, lymphadenopathy Animal Origin Discreet circular patches of hair loss with scaling, inflammation and pustules
GENERAL MANAGEMENT, TREATMENT AND ADVICE Patients with fungal infections should be generally managed as below: Take a sample for microscopy and culture in severe cases or if diagnosis uncertain: Scrape the edge of the lesion and place scrapings in paper, fold and send to laboratory and ensure results are sent to the GP Advise patient about the importance of good hygiene: Daily washing especially between folds of skin and toes and dry well Change clothing daily Do not share towels, flannels, nail files or shoes Avoid scratching Advice patient fingernails can take 4-6 months to grow out and toenails 12-18 months once treated SPECIFIC MANAGEMENT Patients with specific fungal infections should be managed as below: Athletes Foot Wear non-occlusive foot wear and alternate different shoes every 2-3 days
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Wear hosiery made from natural materials and change these daily Use protective footwear if prefers such as flip flops in communal areas or shower rooms Astringents are very useful to prevent reinfection for interdigital problems e.g. surgical spirit used daily - NB avoid broken skin Helpful to advise patients to continue with topical products for 7-10 days after the skin clears of symptoms to avoid reinfection by fungal spores which remain in the skin Groin Infection Change underwear daily Candidal skin infection Keep the skin dry and avoid occlusion Try to leave the area exposed to air at night Advise patients with fungal and ringworm infections, athletes foot and groin infections to see Community Pharmacist re: OTC topical antifungals such as Clotrimazole 1% cream or Daktarin. Apply to the affected area 2/3 times a day for at least 2 weeks after the affected area has healed. Advise the patient to wash their hands after application of cream. If resistant type fungal infections refer to GP. Advise patients with Moccasin type athletes foot to see GP as may need oral antifungual medicines such as Terbinafine or Griseofulvin. Advise patients with mild - moderate fungal nail infections (maximum of 2 nails affected) to see Community Pharmacist re: Amorolfine nail lacquer 5%. Advice the patient to continue topical treatment for 6 months for fingernails and 9-12 months for toenail infections. If more than two nails infected advise the patient to see GP.
FOLLOW UP No need to follow up routinely. If symptoms not resolved 7-14 days or are worsening contact own General Practitioner.
DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital
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GASTROENTERITIS PROTOCOL
EXCLUSIONS Patients under 1 year and over 75 years due to risk of complications Patients who are immunocompromised, including patients taking immunosuppressants or systemic corticosteroids Patients with a history of carditis, pancreatitis or renal failure. ASSESSMENT When assessing patients you should: Some questions to consider when obtaining patient history: Whether any other member of the family or contacts are also unwell Details of any foreign travel History of consumption of unsafe foods History of recent use of medication/chemotherapy Take and record the patients Temperature, pulse, blood pressure and respiration rate. Examine abdomen for tenderness and guarding Assess adults/children (over 1 year - 5 years) with diarrhoea for degree of dehydration as per table (NICE Guideline 84, 2009) and if red flag symptoms refer to ED or Paeds. Some clinical signs and symptoms will vary slightly in adults. No clinical detectable Clinical dehydration Clinical Shock dehydration Appears well Appears to be unwell or deteriorating Decreased level of Alert and responsive Altered responsiveness (e.g. irritable, lethargic) consciousness Normal urine output Decreased urine output Skin colour unchanged Skin colour unchanged Pale or mottled skin Warm extremities Warm extremities Cold extremities
(Remote and Face to Face Assessments)
SYMPTONS
Alert and Responsive Skin colour unchanged Warm extremities Eyes not sunken Moist mucous membranes
(except after a drink)
Skin colour unchanged Warm extremities Sunken eyes Dry mucous membranes
(except for mouth breathers in children)
Tachycardia Tachypnoea Normal peripheral pulses Normal capillary refill time Reduced skin turgor Normal Blood Pressure
Tachycardia Tachypnoea Weak peripheral pulses Prolonged Capillary refill time Hypotension
Normal breathing pattern Normal peripheral pulses Normal Capillary refill time Normal skin turgor Normal blood pressure
SIGNS
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Adults and children (over 1 year - 5 years as per NICE Guideline 84) are deemed to be experiencing a form of gastroenteritis if they display the symptoms listed below: Diagnosis of gastroenteritis is usually made on the basis of clinical symptoms and signs. Diagnostic investigations are rarely needed (see management for when stool specimen required). ACUTE GASTROENTERITIS ADULTS and CHILDREN Presumed to be caused by an infection. Rapid onset of diarrhoea - loose or Lasts up to 14 days but may be much watery stool shorter in time Nausea/vomiting Fever Anorexia Abdominal cramps Bloating or flatulence TRAVELLERS DIARRHOEA ADULTS and CHILDREN Caused by food poisoning and/or infection. Onset of diarrhoea May begin at any time during travel or Nausea/vomiting shortly after return. Occurs especially when Fever travel between developed and developing Anorexia countries. Lasts around 4 days. Abdominal cramps Notifiable to Communicable Disease Control Team at Lescaze Offices. SUSPECTED FOOD POISONING ADULTS and CHILDREN Notifiable to Communicable Disease Control Rapid onset of diarrhoea Team at Nausea/vomiting Devon: Lescaze Offices, Shinners Bridge, Fever Dartington, Devon TQ9 6JE Anorexia 01803 861833. Abdominal cramps Cornwall: Sedgemoor Centre, Priory Road, Bloating or flatulence St Austell, Cornwall PL25 5AS 01726 627881 DYSENTERY - ADULTS and CHILDREN An acute infective gastroenteritis that is Notifiable to Communicable Diseases Control Team.
Loose, small volume stools with blood and mucus. Pyrexia/Fever Abdominal cramps
ANTIBIOTIC ASSOCIATED DIARRHOEA ADULTS and CHILDREN Common consequence of treatment with Diarrhoea antibiotics Mild Nausea/vomiting No toxic features CHRONIC DIARRHOEA ADULTS and CHILDREN Diarrhoea that persists for more than 2 4 More than 3 motions a day weeks Malabsorption Failure to thrive
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FOR INFORMATION ONLY - FROM STOOL CULTURE CONFIRMED SPECIFIC INFECTIONS CAUSING GASTROENTERITIS CAMPYLOBACTERIOSIS Likely Sudden onset of diarrhoea cause is food poisoning Abdominal pain Fever Notifiable to CDCT CRYPTOSPORIDIOSIS Mild to severe watery diarrhoea Settles within 2 weeks ENTERHAEMORRHAGIC Severe, bloody diarrhoea for 5 10 days ESHERICHIA COLI No fever GIARDIASIS Diarrhoea that can last 2-6 weeks or for months Abdominal cramps Weight loss in adults Failure to Thrive in children NON TYPHOID SALMONELLA MANAGEMENT Patients with gastroenteritis should be generally managed as below: Watery, sometimes bloody diarrhoea Abdominal pain Headache Nausea/vomiting, Fever 12 72 hours after infection lasts 4-7 days Diarrhoea often with blood and mucus as with Dysentery Fever Abdominal cramps Lasts 5 -7 days Profuse diarrhoea despite withdrawal of antibiotics Blood in faeces Cramping and abdominal pain Fever Winter vomiting disease as main symptom is vomiting Watery diarrhoea for 12- 60 hours Aching limbs Fever Headache
CLOSTRIDIUM DIFFICILE
NOROVIRUS
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General management Most cases of mild to moderate diarrhoea are self-limiting, are of short duration and do not require laboratory investigation. Stool culture is only required when the patient: Has stools that contain blood Is febrile Appears systemically unwell Has watery diarrhoea present for longer than 4 days Has recently returned from abroad Attend a nursery/child-minder/play-group/school or a day centre Has suspected food poisoning Is a food handler putting other people at risk, or lives with people who handles food for the public Is taking or recently taken a broad-spectrum antibiotic (request Clostridium difficile toxin detection) as these antibiotics are the worst for inducing Clostridium difficile - in particular cephalosporins, clindamycin and quinolones. The safest are doxycycline, gentamycin, trimethoprim and Metronidazole. Is taking or has recently taken chemotherapy Persistent diarrhoea (more than 14 days) requires further stool investigation to exclude parasitic infections such as Giardia, Entamoeba, Cryptosporidium and Cyclospora Adults with gastroenteritis should be generally managed as below: Inform the patient most bouts of gastroenteritis settle within a few days without specific treatment. Aim to prevent dehydration by drinking plenty of normal drinks: Drink at least two litres of fluids in the first 24 hours followed with 200 400ml of ORS (Dioralyte) per loose of stool Eat as normal a diet as possible that is high in carbohydrates (bread, pasta, rice potato) and as soon as possible. Avoid fatty and sugary foods Antimotility drugs are occasionally useful for symptomatic control in adults but is not recommended for acute diarrhoea in young children - advice patient to Consult Community Pharmacist re: OTC Loperamide if required Children over 1 year - 5 years with gastroenteritis should be generally managed as below as per NICE Guideline 84: Refer patient to ED/Paeds if dehydrated and/or red flag signs and symptoms. Inform the parent/carer most bouts of gastroenteritis settle within a few days without specific treatment. If the child is not dehydrated: Advice to keep feeding as normal Encourage bottle or breast feeding, other milk feeds as usual and offer plenty of drinks Advice 5ml/kg oral Rehydration salts (ORS) solution after each large watery stool to: Children who have passed 6 or more diarrhoeal stools in the past 24 hours Children who have vomited 3 or more times in past 24 hours Advice not to have fruit juice or carbonated drinks as this can make diarrhoea worse Written advice sheet for patient/parent. Advice on how to prevent transmission of gastroenteritis.
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People should be advised on how to prevent transmission to other family members or contacts Personal hygiene and hand washing with soap in warm running water and carefully drying them afterwards Adults and Children with gastroenteritis should not share towels Prompt disinfection of contaminated surfaces Prompt washing of soiled clothes Avoidance of food/water if there is a chance of contamination All those affected should usually be excluded from nursery, child minders, school or work until free of diarrhoea and vomiting or as per Infection Control policy. Official DoH policy regarding food handlers is that anyone who has diarrhoea or vomiting must immediately leave the food-handling area and prior to returning to work: Employees should have had no diarrhoea or vomiting for 48 hours after any treatment has ceased Negative stool samples are not a necessary condition for return to work. Adults and Children should avoid swimming pools for two weeks after the last episode of diarrhoea If diarrhoea is due to hepatitis A infection, then employees should remain off work until 7 days after the onset of symptoms (usually jaundice) Specialist advice should be sought in all cases of enteric fever (Typhoid) and haemorrhagic Escherichia coli. Particular care is needed in people with risk factors for poor outcome, such as the very young or elderly. Those with pre-existing medical conditions e.g. immunodeficiency, gastric hypochorhydria, inflammatory bowel disease, valvular heart disease or diabetes mellitus. Those taking certain drugs e.g. systemic corticosteroids, acid suppressant agents, angiotensin-converting enzyme (ACE) inhibitors or diuretics.
FOLLOW UP See own General Practitioner if symptoms not resolved within 48 hours or the patients condition worsens.
DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital
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Current anticoagulant therapy such as warfarin Current drug or alcohol intoxication Suspicion of non-accidental injury Continuing concern by nurse practitioner
Patients presenting with a head injury and also have neck pain or tenderness should have full cervical spine immobilisation unless other factors prevent this. PATIENTS, WHO ARE TRANSFERRED, WILL BE ASSESSED IN ED AND MAY OR MAY NOT BE ADMITTED. ASSESSMENT In the absence of any of the factors listed above, the nurse practitioner should consider referral to the emergency department if any of the following factors are present based on clinical judgement of severity: Irritability/altered behaviour (particularly in young children) Visible trauma to head not covered Adverse social factors - no one able to supervise the injured person at home Continuing concern by the injured person or their carer about the diagnosis.
MANAGEMENT - Adult and Children Patients that meet criteria should be accompanied by a competent adult during transportation to Emergency Department. The nurse practitioner to assess and make clinical decision based on patients condition if an ambulance is required, otherwise they can use own or public transport Supply analgesia as per pain scores as required under PGD Observations should be taken and recorded on a half hourly basis until GCS equal to 15 has been achieved All wounds treated in accordance with wound care protocol If patient requires Tetanus prophylaxis, treat in accordance with Tetanus protocol POST- CONCUSSION SYNDROME History of a recent minor head injury Headache Dizziness Lethargy Lack of concentration GCS =15 Alert and orientated Neurological observations are within normal limits Normal pupil reaction DISCHARGE No patients presenting with a minor head injury or post-concussion syndrome should be discharged until/unless they have a GCS equal to 15
If concerned refer to ED Reassure symptoms will resolve Rest - no IT gaming Advise OTC regular analgesia or supply under PGD Symptomatic treatment Advise to attend ED if symptoms worsen
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If the patient is deemed as safe for discharge they should receive written and verbal head injury advice - discuss with patient/parent/carer actions to be taken if signs and symptoms develop The patient should only be discharged if it is certain there is somebody suitable at home to supervise the patient Write and send routine letter of patient's attendance and treatment to GP. Children under 5 years must have a Health Visitor referral. All other discharge plans as per clinical decision by the nurse practitioner DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital
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MANAGEMENT
Migraine - patients are deemed to have a migraine if they have the following(CKS, 2009): Reassure migraine is self limiting and Recurrent unilateral throbbing headache usually resolves within a few hours - days Nausea Advise lifestyle modification i.e. avoid Photophobia triggers such as chocolate, cheese or Malaise
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Diarrhoea Some patients experience and aura 10-60 minutes before headache - flashing lights or zig zag silvery lines across eyes
alcohol Advise OTC paracetamol or Ibuprofen if not contraindicated or supply under PGD Advice OTC antimigraine drugs such as migraleve Advice if migraines linked to menstrual cycle to see GP Advise patient to see GP/OOH if symptoms worsening or not resolving Advise relaxation/massage or alternative therapies
Note: Migraine is difficult to diagnose if a first attack - if there is no aura, or symptoms not indicative of a migraine the patient should be referred to a doctor.
Tension Headache- patients are deemed to have a tension headache if they have the following: (CKS, 2009) Reassure is self limiting Tightness - like a band to head Advise lifestyle modification if able such as May spread to neck stress Usually wake with a headache and lasts Advise OTC paracetamol or Ibuprofen if all day not contraindicated or supply under PGD Advise patient to see GP/OOH if symptoms worsening or not resolving Advise relaxation/massage or alternative therapies
DISCHARGE
Write and send routine letter of patient's attendance and treatment to GP. Children under 5 years must have a Health Visitor referral. All other discharge plans as per clinical decision by the nurse practitioner No need for a routine GP follow up unless headaches start to follow a pattern
DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital
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GINGIVOSTOMATITIS TYPE HVS 1 (CKS, 2007) Most common presentation in young children Vesicles and ulcers on the General advice about the cause of the tongue, lips, gums, buccal virus, possible reoccurrence and mucosa, hard and soft palates transmission Pain and irritability Treat symptomatically Inability to swallow drooling. Paracetamol/Ibuprofen for pain Loss of appetite relief/pyrexia OTC or as per PGD Dehydration Also advise OTC Benzydamine rinse/spray Fever, cervical or equivalent to relieve pain in the mouth lymphadenopathy, halitosis, Consult Community Pharmacist re OTC lethargy mouthwashes and topical anaesthetics Soft diet for children with Gingivostomatitis and plenty of fluids CHICKEN POX Acute disease caused by HVZ Herpes Varicella Zoster (CKS, 2007) Highly infectious incubation period 10-21 days Very Infectious from 48 hours before rash appears until 6 days afterwards Generalised itchy General advice about the cause of the virus and vesicular rash begins on transmission most infectious period 1-2 days the face and scalp before rash appears but remains infectious until spreading to the trunk scabs crust over. and limbs Keep nails short to minimise damage from Lesions are vesicles with scratching and to prevent secondary infection surrounding erythema Dress appropriately to avoid shivering or develop into pustules and overheating crust over appear in A non-adherent dressing (NA Ultra or equivalent) successive crops over 3- to cover rash when blistered and raw and all 4 days shingle lesions Itchy +++ Avoid transmission by good hygiene measures Rash may involve own towel, flannel and clothes. mucous membranes Also avoid contact with immunocompromised forming multiple mouth people e.g. those receiving cancer treatment, ulcers high doses steroids, pregnant women and infants under 1 month Stay off school/work until lesions crust over and no new lesions appear, there is no pain or malaise Paracetamol/Ibuprofen for pain relief/pyrexia OTC or as per PGD Advice treating itch with OTC Crotamiton cream or equivalent Patients > 12 years whom present within 24 hours of the onset of rash refer to GP/OOH for Aciclovir prescription Advise patient air travel is not allowed until 6 days after the last spot.
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Advise patient to seek urgent medical advice if condition deteriorates or develops complications SHINGLES Herpes Zoster (CKS, 2007) Acute infection caused by reactivation of the latent Varicella zoster virus Advice as per Chicken pox (Herpes ADULTS Varicella Zoster) Paraesthesia and pain over the affected area 2 -7 days before onset of rash Give the patient advice as per Pain over affected site varies from Chicken Pox that present within 72 slight itch/tingling to burning/severe hours of the onset of the rash boring pain to stabbing acute pain Vesicular rash New lesions form over 3-5 days, pustules over 4-6 days and scabbing 7 -10 days Low grade fever and malaise Refer to GP/OOH for treatment CHILDREN - > 6 months No early pain over the affected area Treatment and advise as per in younger children Chicken Pox Mild pain, hyperesthesia and pruritis in older children Mild rash New lesion formation is brief with rapid healing. Completed in 7-14 days POSTHERPETIC NEURALGIA - occurs when pain associated with shingles becomes chronic (CKS, 2007) Age > 50 strongly Advice symptoms can resolve after a few months associated with risk of postherpetic neuralgia. Advice patient to reduce stimulation of the skin by Constant pain which may changing clothing or other external stimulants be burning, aching or Protect sensitive areas by covering with a nonthrobbing. Intense adherent dressing or opsite type dressing or itching. equivalent Does not occur in Ice packs can be used for short term relief of pain children See General Practitioner within 2-3 days REFERRAL PATHWAY If any patient declines treatment/advice refer to GP CHILDREN Children with an extensive rash and systemically unwell Contact Paediatrician at local Hospital or A+ED Arrange transfer to ward/department by ambulance
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Explain actions to the patient/career or significant others and apply wrist band for identification Treat fever with Paracetamol or Ibuprofen as per PGD Observe until transferred Inform ward or ED of transfer OPTHALMIC SHINGLES Patient presenting with a rash near the eye, tip of nose or ear requires referral to the Royal Eye Infirmary
Contact REI or ED Arrange transfer to department Explain actions to the patient/career or significant others
IMMUNOCOMPROMISED PATIENTS Patient who are immunocompromised Refer patient to General have an increased risk of Practitioner/OOH the same day complications DISCHARGE AND FOLLOW UP No need to follow up routinely. To be followed up by General Practitioner if lesions become infected, patient becomes unwell or if rash or pain persists. DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital
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IMPETIGO PROTOCOL
EXCLUSION Nil ASSESSMENT When assessing a patient you should: Impetigo is usually a clinical diagnosis and gloves should be worn when examining the patient. MANAGEMENT, TREATMENT AND ADVICE Patients with symptoms of impetigo should be managed and treated as below: NON BULLOUS IMPETIGO - (CKS, 2007) Most common in young Treat Symptomatically children. History of contact with a Advice patient to soften and remove crusting lesions by person with impetigo up soaking in warm soapy water or mild antiseptic before to 10 days previously. applying topical treatment Generally lesions are Advice patient to maintain strict personal hygiene: around mouth, nose Wash hands after touching patch of impetigo or and extremities. applying topical treatment Initially thin walled Avoid scratching vesicles/pustules on a Keep fingernails clean and short erythematous base Avoid sharing towels, flannels, clothing and (round oozing spots) bathwater until infection cleared Become raw, irregular Remain off work or school until they have had 48 lesions; once ruptured hours of topical treatment produce thick yellowish Treat acute impetigo Fusidic Acid cream as per PGD or brown crust- may be via GP/OOH if risk of infecting other individuals multiple. No pain. BULLOUS IMPETIGO (CKS, 2007) The trunk area is most commonly affected Flaccid fluid filled multiple vesicles/blisters 1-2 cm diameter that spread rapidly Thin, flat brown crusts form over ruptures lesion Lesions extend outwards with central healing and may give rise to annular lesions May be itchy/painful Systemic signs fever, lymphadenophy and general malaise
As per Non-bullous impetigo If extensive infection, longstanding or systemic illness treat with Flucloxacillin as per PGD or Erythromycin PGD if allergic to penicillin Swab lesion if person has been in contact with someone known to have MRSA- results to GP If extensive infection, longstanding or systemic illness treat with Flucloxacillin as per PGD or Erythromycin PGD if allergic to penicillin
DOCUMENTATION. DISCHARGE AND FOLLOW UP No need to follow up routinely. If lesions have not cleared in 7 days or are worsening contact own General Practitioner. In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital
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DISCHARGE PLAN Patients who have no clinical symptoms require no specific follow up. Advice the patient however, that if they do develop any symptoms to contact a doctor. Symptoms include difficulty in swallowing, sustained coughing or dyspnoea, vomiting or abdominal pain. Unless the swallowed item is of value or sentimental worth then there is no indication to search the stools to prove that the foreign body has passed Write and send routine letter of patient's attendance and treatment to GP. Children under 5 years must have a Health Visitor referral. All other discharge plans as per clinical decision by the nurse practitioner DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital
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MANAGEMENT Patients with an ingrowing toenail should be managed as below: Clean nail and apply dry dressing for comfort Advise OTC analgesia if painful Advise on local nailfold care - to keep dry and dressed until seen by podiatry. Bathe area with salty water and dry. Advise on nail cutting Refer to podiatry service if persistent/recurrent with current referral form indicating full extent of the problem including history and infections DISCHARGE Advice the patient to see GP if symptoms not resolving Write and send routine letter of patient's attendance and treatment to GP. Children under 5 years must have a Health Visitor referral. All other discharge plans as per clinical decision by the nurse practitioner
DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital
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MENINGITIS (SUSPECTED)
Meningitis can kill an otherwise healthy person within hours of the first symptoms: if in doubt refer urgently. Young adults and babies are at particular risk. The two main clinical presentations, Septicaemia and Meningitis, can occur on their own but often appear together. Septicaemia without signs of meningitis is far more life-threatening.
ASSESSMENT When assessing a patient you should: Remember that bacteria and viruses other than meningococcus can cause symptoms of meningitis. Early signs may be rather non specific. Patients are suspected to have meningococcal disease if they display the symptoms listed below: ADULTS: SEPTICAEMIA - can occur with or without meningitis (CKS, 2007 and Meningitis Research Foundation 2002) Septicaemia causes shock, which can lead to multi-organ failure. SYMPTOMS: Fever Vomiting Pale/blotchy skin Drowsiness Confusion Tachyapnoea Shivering Cold hands/feet Aching joints Rash - tiny bright red spots Hypotension Dizziness MENINGITIS - (CKS, 2007 and Meningitis Research Foundation 2002)
EARLY SYMPTOMS: Fever Nausea/vomiting Severe headache Muscle/leg pains Cold hands/feet Pale blotchy skin LATE SYMPTOMS: Neck stiffness Drowsiness Photophobia Confusion Seizures Non blanching rash anywhere on the body
CHILDREN OVER 3 MONTHS - 16 YEARS- (CKS, 2007 and Meningitis Research Foundation 2002) Symptom/sign Bacterial Meningococcal Meningococcal Notes meningitis disease septicaemia Common non-specific symptoms/signs Not always present especially Fever in neonates Vomiting/nausea
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Lethargy Irritable/unsettled Ill appearance Refusing food/drink Headache Muscle ache/joint pain Respiratory symptoms - DIB Chills/shivers Diarrhoea/abdo pain Sore throat or ENT symptoms Non-blanching rash Stiff neck Altered mental state Capillary refill time more than 2 seconds Unusual skin colour Shock Hypotension Leg pain Cold hands/feet Back rigidity Bulging fontanelle
Photophobia Kenig's sign Brudzinski's sign Unconsciousness Toxic/moribund state Paresis Focal neurological deficit Seizures Signs of shock: Capillary refill time more than 2 seconds Unusual skin colour Tachycardia and/or hypotension Respiratory symptoms or DIB Leg pain Cold hands/feet Toxic/moribund state
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Altered mental state/decreased conscious level Poor urine output = symptom/sign present X = symptom/sign not present NK = not known if a symptom/sign is present (not reported in the evidence) NORMAL VALUES OF VITAL SIGNS Age (years) Heart Rate per minute <1 110 160 12 100 150 25 95 140 5 12 80 120 Over 12 60 - 100 Respiratory rate per minute 30 40 25 35 25 30 20 25 15 - 20 Systolic Blood Pressure 70 90 80 95 80 100 90 110 100 - 120
SpO2 Oxygen Saturation: normal value >95% in air. If SpO monitor is not picking up, check perfusion capillary refill should be < 2 seconds.
MANAGEMENT Adults and children deemed to have septicaemia or meningitis should be managed as below: DIAL 9 999 and arrange transfer to Emergency Department, PHT IMMEDIATELY. Transfer patients with suspected bacterial meningitis without non-blanching rash directly to ED without giving antibiotics Transfer patients with suspected meningococcal disease (meningitis with non-blanching rash or meningococcal septicaemia) with a stat dose of BENZYLPENICILLIN as per PGD at the earliest possibility but do not delay urgent transfer to ED to give antibiotics. Do not give Benzyl Penicillin if patients have a clear history of anaphylaxis after a previous dose of penicillin. Do not routinely administer oxygen, but monitor oxygen saturation levels with pulse oximetry as soon as possible. Offer supplemental Oxygen as per PGD to:Patients with oxygen saturation (Sp02) of less than 94% who are not at risk of hypercapnic respiratory failure, aiming for Sp02 of 94-98%. Give 40%60% oxygen at a flow rate of 410 L/minute (depending on brand of mask). Use a reservoir (non-rebreathing) mask if the patient is severely hypoxic or if saturation monitor is not picking up a signal due to poor peripheral perfusion. Contact the Emergency Department, PHT to advise them of patients imminent arrival. Ensure the patient has an Identification band as per Patient Identification Protocol 2008. DISCHARGE & DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital
NAIL INJURIES
EXCLUSIONS Patients with Diabetes Obvious damage to the nail bed ASSESSMENT When assessing a patient you should: Ascertain history Examine to exclude nail bed laceration Consider whether underlying fracture is possible MANAGEMENT Patients with partially avulsed nail injuries (own or acrylic), subungual haematoma or foreign body under the nail should be managed as below: NAIL INJURIES Avulsed or partially avulsed nail patients own or acrylic If new injury - Either trim nail, remove or replace avulsed nail under the eponychium using local anaesthetic Lidocaine as per PGD Clean and Reinsert nail into nail fold - not great toenails as they will not reinsert If old and nail bed dry, or great toenails, remove nail, clean and dress Apply Steristrip to hold nail in place and inadine dressing Give the patient dressing clinic appointment for 2 days and advice they will require further change dressing in 3-5 days Nail care advice Xray if bony tenderness to exclude # - if a # is identified follow compound Distal Phalanx management - page Trephine nail and drain Dress with finger dressing 3-5 days Patients suffering from: Peripheral Vascular Disease, Diabetes or Steroid Therapy must be referred to GP If easily visible or palpable remove FB with splinter forceps Xray to detect metal or glass if required Remove FB under local anaesthetic per Lidocaine PGD if not contraindicated - may need to shave or cut V in nail - if unable to remove in total refer to ED Document removal and show patient. Clean and dress 3-5 days
Subungual haematoma
DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital
Decreased range of neck movements - less than 45 degrees Headache, Dizziness, Nausea, Jaw pain Paraesthesia and/or Neurological problems in upper or lower limbs Posterior cervical sympathetic syndrome (feeling of ants crawling over face) GCS less than 15
Inform ED of patients imminent arrival If injury over 2 days and does not meet Canadian rules send the patient in own transport to ED Supply analgesia according o pain score and as per PGD
WHIPLASH - Low risk Factor which allows safe assessment of range of movement - (Canadian c-spine rules, 2003. CKS, 2010) - no x-ray required Patient presents with no high risk factors Simple rear end shunt - excluding double shunt, pushed into oncoming traffic, hit by a bus/lorry, rollover or hit by high speed vehicle Sitting position without pain Walking at any time Delayed onset of neck pain - not at time of collision Absence of midline c-spine tenderness Able to actively rotate neck 45 degrees left and right If able to rotate neck 45 Symptoms may be delayed for hours or days Neck pain - may radiate to shoulder or upper arm degrees left and right reassure No midline c-spine tenderness If not able to rotate neck 45 Some will have back pain degrees left and right - refer to Headache ED and follow acute Fatigue, dizziness, nausea management Paraesthesia Advice OTC or supply analgesia Some decrease in range of movement to neck as per PGD Normal GCS - 15 Encourage exercises and Alert movement of neck No painful distracting injuries Advice not to use of a neck No focal neurological deficits collar as delays recovery If the patient has any abnormal findings or nurse practitioner has clinical concerns refer patient to a doctor
DOCUMENTATION & DISCHARGE PLAN In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital Written instructions on neck whiplash care Advise the patient that if symptoms are not resolving within one week to see their GP for physiotherapy referral. Guidelines on abnormal signs/symptoms should be given to the patient and when to arrange follow-up with doctor if required.
NECK PAIN
EXCLUSIONS
Patients who have been involved in trauma - see neck 'whiplash' protocol Patients whose injuries involve suspected fractures, dislocations or spinal cord injuries. Patients, who have any neurological signs and symptoms, see Minor Head Injury protocol exclusions. Patients with osteoporosis, premature menopause or use steroids ASSESSMENT When assessing a patient you should: Obtain full history of events leading to the onset of pain Check whether previous episodes Ascertain full past medical history Examine neck and upper limb neurology MANAGEMENT Patients deemed to have a torticollis or wry neck should be managed as below: TORTICOLLIS -(CKS, 2009) Minor musculoskeletal injury caused by twisting the neck No history of trauma Advice self limiting and usually resolves in A history of localised exposure to cold, 48 hours but may take longer prolonged position or unusual posture Recurrence is common Sudden onset of pain - usually unilateral Advise OTC regular analgesia Deviation of neck to one side Advise gentle exercise Pain may radiate to shoulder/upper arm Advise intermittent heat and or cold packs Headache to reduce pain Neck feels stuck in one position Advise sleeping on firm pillow No c-spine tenderness Advise not to use of a neck collar as Decreased range of movement delays recovery Note: beware of torticollis in children especially following even minor trauma DISCHARGE & DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital Written instructions on neck strain care Advise the patient that if symptoms are not resolving within one week to see their GP for physiotherapy referral. Guidelines on abnormal signs/symptoms should be given to the patient and when to arrange follow-up with doctor if required.
ASSESSMENT When assessing a patient you should: Obtain a detailed history of the event including use of any eye protection. Examine: The patients visual acuity The patients pupil reaction Any evidence of inflammation A simple sketch may be helpful in recording. MANAGEMENT Patients deemed to have a foreign body to the eye should be managed as below: Instil 1 drop Proxymetacaine Hydrochloride 0.5% (Minims) as per PGD. Remove the sub-tarsal and Conjunctival foreign bodies (provided that the foreign body comes off easily with a cotton bud dampened with sterile saline). Patients (not excluded from Fluorescein PGD refer to REI if they are) with a suspected Conjunctival/Subtarsal foreign body should have Fluorescein dye applied to exclude the presence of corneal abrasion. After the removal of foreign body, administer 1-drop Fluorescein 2% (Minims) stat as per PGD and examine the eye. The removal of a FB that leaves an abrasion, no matter how small, should be treated with an initial covering dose of Chloramphenicol eye ointment whilst in the unit and instructions as per PGD.
Any indication of rust remnants must be referred to the Eye hospital for advice. Large corneal abrasion, refer to REI. For patients with minor corneal damage, apply Chloramphenicol ointment once whilst patient is in the unit, then advise patient to continue use Chloramphenicol eye ointment as per PGD 4 to 5 times a day for 3 - 5 days until asymptomatic. If no corneal damage apply Chloramphenicol 1% eye ointment stat.
INFECTIVE CONJUNCTIVITIS When assessing a patient you should: Obtain a history and undertake visual examination of the eye, and visual acuity test Patients deemed to have infective conjunctivitis if they have the following: Unilateral red eye with weeping/discharge (Bilateral symptoms can occur with spread but always unilateral initially) Oedema to upper eyelids Inflammation to conjunctiva Red watery eyes Sticky eyes - glued together by discharge after sleep History of close contact with another infected person MANAGEMENT Advise usually self limiting and usually settles without treatment within 1-2 weeks Remove contact lenses and do not use until symptoms resolved Treat with Chloramphenical 0.5% eye drops as per PGD or OTC Advise to wash hands before and after applying drops Advise to bathe eye/s before applying drops with warm water before applying drops Strict personal hygiene If symptoms do not resolve to contact GP ALLERGIC CONJUNCTIVITIS ASSESSMENT When assessing a patient you should: Obtain a history and undertake visual examination of the eye, and visual acuity test Patients deemed to have allergic conjunctivitis if they have the symptoms below: Bilateral itchy eyes Oedema to upper eyelids Inflammation to conjunctiva Red watery eyes History of exposure to known allergen History of hayfever
MANAGEMENT Advice the patient to remove contact lenses if applicable. Avoid rubbing eyes Avoid exposure to the allergen if practical Use cool compresses on the affected eyes To discuss with community pharmacist OTC: topical ocular antihistamine drops. Discuss with patient the use of oral non-drowsy antihistamines as they may also be required if acute CHEMICAL SPLASHES ASSESSMENT When assessing a patient you should: Obtain a history including the use of any eye protection. The nurse should obtain details of the solution spilt; its pH and any special precautions. Examine: The patients visual acuity The patients pupil reaction Any evidence of inflammation Information may be obtained from the Poison Information Services or Toxbase. MANAGEMENT Patients deemed to have a chemical splash to the eye should be managed as below: Instil 1-2 drops Proxymetacaine Hydrochloride 0.5% (Minims) as per PGD, before procedure, if necessary for deeper anaesthesia, 1 drop every 5 - 10 minutes, for 5 - 7 applications. Check pH of eye(s) (Normal pH of eye is 7.5). All chemical injuries should be irrigated copiously with sodium chloride 0.9%, at least one litre. Recommended 30 minutes irrigation, Test pH after 20 minutes and record on attendance card. Irrigation should continue until the pH is normal. Refer the patient to the REI for further treatment - All alkaline splashes must be referred to the Ophthalmic Specialist Patients with a suspected, penetrating ophthalmic injury, must not be padded. If patients have had eye pads applied, they must be advised not to drive or operate machinery whilst wearing an eye pad and that the pads are inflammable. DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital Advice the patient that if symptoms do not resolve or worsen to contact REI 9-5 Monday Friday
POISONING
EXCLUSIONS Patients that have taken a treatable overdose as a deliberate self harm. When advised by the National Poisons Unit - Toxbase that the patient requires assessment and treatment by a doctor. PATIENTS EXCLUDED MUST BE REFERRED TO A DOCTOR IMMEDIATELY. ASSESSMENT When assessing a patient you should: Note: Date, time, substance and amount of substance ingested Temperature, pulse and blood pressure Respiratory rate and any respiratory distress Patient's weight Whether patient has vomited or not Any other symptoms Assess the patients mental health status using the Self Harm assessment tool where applicable. MANAGEMENT Advice should be sought on an individual basis via the Toxbase web site (use username and password to access) for NHS staff or the UK National Poisons Units
DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital
PSORIASIS PROTOCOL
EXCLUSIONS Patients with plaques that are not located on elbows, knees, scalp or lower back. Patients with known psoriasis with painful, swollen stiff joints to fingers and toes. ASSESSMENT When assessing a patient you should: Diagnosis is made from a detailed history and examination of the individual. Patients are deemed to have psoriasis if they display the symptoms listed below: Well defined single or multiple red plaques Raised patches with overlying flaky white scaly surface to the skin. Plaques are predominantly on elbows, knees, scalp and lower back. Pruritus to the skin.
MANAGEMENT, TREATMENT AND ADVICE - (CKS, 2007) Patients with psoriasis should be managed as listed below: Advise patient self care and about keeping skin hydrated and smooth Advise patient to expose their affected skin to the sun for limited periods (but that they must use sunscreen) Advice patient to discuss with Community Pharmacist OTC: tar based shampoos and emollient preparations. Plaques: consult community pharmacist re: OTC emollients such as Diprobase cream For thicker patches of dry/scaly plaques consult community pharmacist for: OTC Hydrocortisone 1% ointment.
DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital
RESUSCITATION PROTOCOL
All nurses working in the Minor Injuries Unit will be trained in basic life support and nurse practitioners in advisory external defibrillation training in accordance with European Resuscitation Council (UK) Guidelines and will receive the PCH mandatory Basic Life Support (BLS), Immediate Life Support (ILS) & Advisory External Defibrillation (AED) training yearly updates.
All resuscitation procedures must be in accordance with the Resuscitation Council (UK) guidelines 2010 and the PtPCH Resuscitation policy 2009 plus subsequent reviews. Any patient, visitor or member of staff who suffers collapse/sudden unexpected death will have resuscitation attempted. Where indicated, the first member of staff on the scene will start to implement basic life support until further assistance arrives. ADULT and PAEDIATRIC BASIC LIFE SUPPORT ALGORITHM When assessing a collapsed unresponsive patient you should: Follow Resuscitation Council (UK) 2010 Adult or Paediatric BLS Algorithm and any subsequent updates that are developed in the life of these protocols. Ensure the safety of the rescuer and the patient before you approach Check the patient for a response - gently shake their shoulders or foot for an infant and ask loudly 'are you all right'. Do not shake an infant/child if suspected C.Spine injury. If the patient responds leave them in the position in which you found them provided there is no further danger, try to find out what is wrong and take the appropriate actions. Reassess regularly. If no response SHOUT for help Place the patient on their back and open the airway using head tilt and chin lift unless trauma is suspected then jaw thrust. Check for signs of life:Keeping the airway open, look, listen, and feel for normal breathing or taking infrequent, irregular, noisy gasps (agonal breathing) or cough for no more than10 seconds (only remove dentures if ill fitting). If breathing normally place in recovery position and call for an ambulance. Simultaneously assess Carotid pulse in child over 1 year and adults. In infants check Bracheal Pulse. If there are no signs of life in a child/infant or a definite pulse, or if a pulse is below 60 beats/min then continue with CPR If the patient is not breathing Summon assistance - call for help or pull emergency bell Summon ambulance by telephoning 9 999 giving postcode and site address and asking for a ED if available Start chest compressions as below to a rate of 100 -120 times per minute (approx 2 compressions per second) Combine chest compressions with rescue breaths as below at a rate of one breath per second - inspiratory time of 1 second (Any longer may result in oesophageal-opening pressure and increase risk of regurgitation) and give enough volume to produce chest rise as in normal breathing.
ADULTS 30 Chest Compressions : 2 Rescue/Inflation breaths Depth of compression approx 6 cms INFANTS If Two rescuers Under 1 5 Rescue Breaths: 15 Chest Compressions : 2 Breaths 1 year - puberty 5 Rescue Breaths: 15 Chest Compressions : 2 Breaths If one rescuers Under 1 5 Rescue Breaths: 30 Chest Compressions : 2 Breaths 1 year - puberty 5 Rescue Breaths: 30 Chest Compressions : 2 Breaths Change over CPR about every one - two minutes to prevent fatigue until ambulance arrives. Continue resuscitation until the patient shows signs of life (normal breathing, movement and in children/infants a pulse greater than 60 min) or consciousness in adults. Stop only to recheck the patient if they start breathing normally otherwise do not interrupt resuscitation. Continue resuscitation until: Ambulance arrives to take over The patient starts breathing normally You become exhausted
Other members of the MIU staff to arrange the following. Summon ambulance by telephoning 9 999 giving postcode and address if not already done and request assistance for urgent transfer. Bring AED and emergency trolley to side of patient Attach AED electrodes to the patients bare chest Assist with CPR - change over every one - two minutes Prepare clinical notes if applicable otherwise give verbal handover. Assist with transferring the patient to the MIU resuscitation room if applicable. Ensure the patient has an Identification band as per procedure 2008. Support or inform relatives Connect suction ready for use Connect to cardiac monitor and pulse oximeter if applicable Reception staff copy clinical notes and have any other documentation ready for transfer with the patient. Inform ED of patients attendance. ADULT and PAEDIATRIC ADVANCED LIFE SUPPORT: Follow Resuscitation Council (UK) 2010 Adult or Child BLS Algorithm until AED FR2 Heartstart monitor arrives and is attached. CPR 30:2 for adults and CPR 15:2 for infants and children Attach patient to FR2 Heartstart monitor to assess cardiac rhythm. Non-Shockable rhythm continue with CPR 30:2 for 2 minutes. Continue as directed by the voice/visual prompts.
If shock is indicated: Ensure no one touches the patient or immediate area, push the shock button as directed ( attached AED will advise and deliver the shock automatically) Continue as directed by the voice/visual prompts and immediately resume CPR 30:2 for 2 minutes. Continue the cycle until help arrives ALL emergency situations: Do not routinely administer oxygen, but monitor oxygen saturation levels with pulse oximetry as soon as possible. Give patient supplemental Oxygen as per PGD - 40%60% oxygen at a flow rate of 4-10 L/minute (depending on brand of mask). Use a reservoir (non-rebreathing) mask if the patient is severely hypoxic or in major trauma. In some cases, local policies may include the use of 100% oxygen from a reservoir mask. Gain IV access if competent to do so and if time permits. Sodium Chloride 0.9% injection as a flush as per PGD Continue to monitor cardiac output and patient until 999 ambulance arrives.
ADULT and PAEDIATRIC CHOKING ALGORITHM Assess severity: Mild airway obstruction - encourage the patient to lean forward and cough Continue to check for deterioration to ineffective cough or relief of obstruction Severe airway obstruction and cough ineffectual: If conscious give 5 back blows followed by 5 abdominal thrusts (chest thrusts for an infant under 1 year) until resolved or condition deteriorates check if dislodged FB after each blow/thrust If unconscious start BLS as above for an adult and if a child/infant give 5 breaths then CPR
MAINTENANCE OF RESUSCITATION EQUIPMENT. The manager in charge of the MIU is responsible for ensuring that emergency equipment is fit for purpose and regularly monitored, maintained and in good working order and that stock is in date. The nurse in charge is responsible for ensuring that staff know how to use equipment, that equipment is properly checked daily and after use, records are completed and faults reported. Staff have a responsibility to ensure they are trained to use the equipment, carry out and record daily checks and after use and report any problems/faults to nurse in charge and estates/MEMS. See medical devices policy.
POST RESUSCITATION PROCEDURES Following resuscitation attempts, staff should be offered debriefing by the nurse in charge to allow open discussion of the events. Ensure Completion of the Resuscitation Incident/Audit Form for clinical records
DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital
SCABIES PROTOCOL
EXCLUSION Age < 2 and age > 60 years The immunocompromised patient with signs and symptoms of scabies Pregnant women and women who are breastfeeding Patients on steroids Patients with crusted scabies (Norwegian Scabies) or secondary infection Patients with a known allergy to Chrysanthemums These patients must be referred to General Practitioner ASSESSMENT When assessing a patient you should: Diagnosis of scabies is made from patients history and examination of the individual. Misdiagnosis is common because of scabies similarity to other pruritic skin disorders MANAGEMENT, TREATMENT AND ADVICE Patients with scabies symptoms should be managed and treated as listed below: SCABIES - (CKS, 2007) History of contact with a person with scabies up to 2 6 weeks previously Generalised itching that is more intense at night lasts up to 3-4 weeks Widespread eruption of inflammatory papules/vesicles associated with burrows Burrows may be seen with naked eye but magnifying goggles are better appear as fine greyish/dark wavy lines with a minute speck at closed end Most common areas General Advice affected Adults and older children Between fingers forearms axilla, peri arealor area of the breasts, abdomen, buttocks and thighs firm red nodules may develop on elbows, anterior axillary folds Infants > 2 years face, head, neck, trunk, scalp, palms and soles Burrow ink test rub a non-toxic water soluble felt tip pen marker over papule/vesicle wait a few minutes wipe off with alcohol wipe if burrow present ink will track down mite burrow Advice that all family members, close contact and sexual contacts are treated within 24hrs see own GP Patient requires a prescription from GP/OOH Permethrin 5% Lotion or Advice patient to consult community pharmacist re: OTC Lyclear dermal cream. Apply before going to bed to the whole body, including scalp, face, neck and ears as per PGD. Do
not apply after hot bath. Reapply if skin is washed or becomes wet. Leave for 8-12 hours and wash off in the morning. Repeat after 7 days. Treat symptomatically Advise patient that all members of the household, close contacts and sexual contacts should be treated within 24 hours of the person presenting to unit even if they themselves do not have symptoms of scabiesadvise to contact own GP. Advice strict personal hygiene Own bedding, clothing, towels and flannels Wash clothes in machine at 50C or above on the day of 1st application. Keep clothes that cannot be washed immediately in a plastic bag for 72 hours Or put clothes in hot tumble dryer for 10-30 minutes Itch Can return to school or work after the first application has been completed It is not necessary to fumigate the house, furniture or pets
CRUSTED SCABIES ( NORWEGIAN SCABIES) hyperinfection of mites in exfoliating scales of skin - (CKS, 2007) Hyperkeratotic warty crusts usually on hands and feet Refer to General Grossly thickened horny layer is honeycombed with burrows Erythema and scaling may occur on face, neck, scalp and trunk Practitioner the same day Nail hyperkeratotsis debris under nails Commonly bacterial secondary infection
FOLLOW UP No need to follow up routinely. If symptoms not resolved within 6 weeks are worsening contact own General Practitioner. DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital
SINUSITIS
EXCLUSIONS Patient presents with; Vacuum sinus pain, Temporo-mandibular joint dysfunction, Atypical migraine, Trigeminal neuralgia, Temporal arteritis, Acute glaucoma, and Facial trauma must be referred to their GP. Dental abscess refer to dental protocol. Children under 12 years of age must be referred to their GP because Sinusitis is very difficult to define in children as upper respiratory tract infections are very common, and these can run into each other to give the impression of a prolonged illness. Children may exhibit some of the symptoms listed above, but facial pain and headache are rare in young children who may have other symptoms such as: snoring, mouth breathing, feeding difficulty, hyponasal speech. ASSESSMENT When assessing a patient you should: The patient may present with these symptoms; Nasal congestion, painful mastication, general malaise, facial pain/tendernesspredominantly on one side, headache this may be worse when leaning forwards, reduced smell (hyposmia), pyrexia, maxillary toothache or pain upon chewing. The diagnosis is usually made from the overall clinical impression. It is often difficult to differentiate viral and bacterial sinusitis, as bacterial sinusitis is usually preceded by a viral infection. Allergic rhinitis can cause similar symptoms. Patients who have History of recently started taking NSAIDs or ACE inhibitors may develop allergy allergic rhinitis. Patients with temperatures of less than 38o C Patients are likely to have a viral infection rather than a bacterial infection.
Differential diagnosis Facial pain or headache can also indicate: Vacuum sinus pain, Temporo-mandibular joint dysfunction, Atypical migraine, Trigeminal neuralgia, Temporal arteritis, Acute glaucoma, Facial trauma,
Acute sinusitis - (CKS, 2009) Acute sinusitis is an infection of one or more of the paranasal sinuses. It usually follows a common cold, and can last up to 4 weeks. Only 0.5 2% of common colds go on to bacterial sinus infection, and there is evidence that acute sinusitis is over diagnosed in primary care. Viral sinusitis - (CKS, 2009) Viral sinusitis usually only lasts up to a week and is treated symptomatically. And may present with one or more of the following; Nasal congestion, painful mastication, general malaise, facial pain/tendernesspredominantly on one side, headache this may be worse when leaning forwards, reduced smell (hyposmia), pyrexia. maxillary toothache or pain upon chewing.
Bacterial sinusitis: - (CKS, 2009) one or more of the above with: Pyrexia of more than 38oC, A second phase in the illness (double sickening) when the patient had thought that they were getting better, and then their symptoms get worse again. A purulent nasal discharge of more than 7 days duration, Presence of pus in the nasal cavity. In extreme cases redness and severe swelling of the cheek and orbit may be present. MANAGEMENT / TREATMENT AND ADVICE Patients with nasal congestion, adults and children with acute bacterial sinusitis should be managed as below: NASAL CONGESTION - (CKS, 2009) Treat symptomatically Advise patient to take OTC paracetamol for reduction of fever and or OCT decongestants Encourage patient to increase oral fluid intake Advise them that if their symptoms worsen or are no better after 10 days that they should see to their GP for further assessment. ADULTS AND CHILDREN OVER 12 WITH ACUTE BACTERIAL SINUSITIS - (CKS, 2009) Adults and children over Treat with Amoxycillin as per PGD for 7 days 12 with: Advise patient to take OTC paracetamol for pain relief and o a) A fever of 38 C or reduction of fever and or OTC decongestants b) Who have had Encourage patient to increase oral fluid intake symptoms persisting Warn patient that symptoms may continue for up to 4 more than 7 days weeks with this episode, and can reoccur thereafter If symptoms persist after 4 weeks, they should make an appointment to see their GP Use Erythromycin 250mg as per PGD for 7 days If patient has a penicillin allergy CHILDREN UNDER 12 YEARS WITH SYMPTOMS OF ACUTE SINUSITIS Children under 12 years with symptoms Refer for same day GP appointment or to of acute sinusitis the Out of hours GP service PATIENT FOLLOW UP For patients treated with antibiotics - If symptoms not resolved after 5-7 days or if symptoms deteriorate then they should contact their General Practitioner The patient demonstrates understanding on how to manage subsequent episodes of sinusitis DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital
Go to Suspected Meningitis If non-blanching purpuric rash associated o with sore throat, temperature> 37 C, Protocol generalised neck stiffness or headache Rash may be blanching in early stage of meningitis If LARGE unilateral tonsil swelling associated with pus, note: no swelling if patient has had tonsillectomy If prolonged lymphadenopathy with malaise Go to referral pathway for ? Quinsy
Go to referral pathway for? Glandular Fever Go to referral pathway for ? Scarlet fever
If red, papular rash with sandpaper texture located on chest associated with sore throat, lymphadenopathy, temperature>37oC and
pus/exudate If normal oropharynx with earache If temperature <37oC associated with generalised redness of tonsils, minimal inflammation or Coryza, or mildly inflamed oropharynx Go to protocol for Earache Go to treatment pathway for Viral Sore Throat
If patients with acute tonsillitis present with the following symptoms: If generalised macular rash with Bilateral swelling Inflammation of tonsils Exudate or pus on tonsils Temperature> 37C Petichiae on palate Lymphadenopathy If marked swelling with exudate or pus on tonsils Sore throat associated with hoarseness
REFERRAL PATHWAYS Patients with sore throat illnesses listed that are outside the protocols should be referred as below: EPIGLOTTITIS (CKS, 2009) Requires Arrange transfer to Emergency Department by calling 9 999. emergency Maintain airway and administer Oxygen as per PGD if oxygen transfer to A&E saturation levels fall below 94% with pulse oximetry via non rebreathing mask. Observe until transfer. Explain actions to patient and significant others. Inform Emergency Department of impending transfer. QUINSY (CKS, 2009) Requires Arrange transfer to Emergency Department by calling 9 999. emergency Maintain airway and administer Oxygen as per PGD if oxygen transfer to AED saturation levels fall below 94% with pulse oximetry via non rebreathing mask. Observe until transfer. Inform Emergency Department of impending transfer IMMUNOCOMPROMISED PATIENTS Patient is and has increased risk of complications
SCARLET FEVER (CKS, 2009) Treat with Phenoxymethylpenicillin as per PGD. Consider use of syrup if swallowing difficult Paracetamol for pain relief/antipyretic or aspirin gargles for those over age 16. Patient may choose to spit out aspirin after gargling and use paracetamol. Advise patient that aspirin can cause gastric upsets. Consult community pharmacist re: OTC throat lozenges. Advice rest until temperature returns to normal; increase fluid intake. Follow up with General Practitioner next working day Treat with Erythromycin as per PGD In patients with penicillin sensitivity GLANDULAR FEVER (CKS, 2009) Refer to General Advice next available appointment Practitioner Advice rest until temperature returns to normal Avoid alcohol Paracetamol for analgesia and pyrexia (OTC medication) Increase fluid intake TREATMENT AND ADVICE Patients with sore throat illnesses listed that are within the protocols should be treated as below: LARYNGITIS (CKS, 2009) Patients with Explain sore throat whether bacterial or viral are usually selfmild/moderate limiting illnesses, antibiotics will not alter the course of that illness. sore throat and Rest voice recent Encourage increase in fluid intake; hoarseness Rest until temperature returns to normal, patients may find saltwater gargles soothing. Advice OTC Paracetamol for pain relief/antipyretic or aspirin gargles for those over age 16. Patient may choose to spit out aspirin after gargling and use paracetamol. Advise patient that aspirin can cause gastric upsets. Consult community pharmacist re: OTC throat lozenges. VIRAL INFECTION (CKS, 2009) Patients with Explain sore throat whether bacterial or viral are usually generalised redness of self-limiting illnesses, antibiotics are unlikely to alter the pharynx, course of that illness. minimal inflammation, Advice increase in fluid intake temperature <37 C Rest until temperature returns to normal and coryza Patients may find salt water gargles soothing
Paracetamol for pain relief/antipyretic or aspirin gargles for those over age 16. Patient may choose to spit out aspirin after gargling and use paracetamol. Advise patient that aspirin can cause gastric upsets. Consult community pharmacist re: OTC throat lozenges. ACUTE TONSILLITIS (CKS, 2009) Patients with sore Treat with Phenoxymethylpenicillin as per PGD. throat and bilateral Consider use of syrup if swallowing difficult. Ensure all swelling, women taking oral contraceptive pill are advised on extra Inflammation of tonsils precautions. with exudate or pus; Paracetamol for pain relief/antipyretic or aspirin gargles for Associated with any those over age 16. Patient may choose to spit out aspirin one of the following: after gargling and use paracetamol. Advise patient that Temperature > 38c, aspirin can cause gastric upsets. lymphadenopathy or Consult community pharmacist re: OTC throat lozenges. macular rash. Advice rest until temperature returns to normal. Increase fluid intake. Patients may find salt water gargles soothing, advise on method of preparation In patients with penicillin sensitivity Patients with recurrent tonsillitis (more than 6 episodes per year) PATIENT FOLLOW UP For patients treated with antibiotics Treat with Erythromycin as per PGD Should be followed up by General Practitioner.
If symptoms not resolving after 3-4 days or if symptoms deteriorate then they should contact their General Practitioner Patients whose symptoms persist Advice patient to seek assessment by their over two weeks General Practitioner Patients with recurrent episodes Patient should be followed up by their General of tonsillitis Practitioner The patient demonstrates an understanding of how to manage subsequent episodes of sore throat DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital
EXCLUSIONS If patient is ill, consider Toxic Shock Syndrome and refer patient to Derriford if they show any of the following symptoms: sudden high fever, vomiting, rash, diarrhoea, faintness, aches, dizziness.
ASSESSMENT When assessing a patient, you should: History of incident Take and record Temperature, Pulse, and Respiration Rate.
MANAGEMENT To assist removal of tampon by practitioner use: Cusco's speculum Long handled forceps A good light source If there is heavy blood loss refer patient to GP or Derriford If there are any abnormal findings refer patient to GP If the nurse experiences any difficulties with the removal of the tampon refer the patient to a doctor Provide leaflet and discuss with the patient toxic shock syndrome and symptoms to be aware of - sudden high fever, vomiting, rash, diarrhoea, faintness, aches, dizziness - if any of these to contact NHS Direct or GP
DOCUMENTATION AND DISCHARGE In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital Record any abnormal finding i.e. any vaginal discharge, sores or lesions if present. Advice patient to see own GP if there is a smelly discharge or patient becomes ill, as antibiotics may be required. Advice should be given in order to prevent a recurrence of the problem. Routine letter of attendance to GP
URTICARIA PROTOCOL
EXCLUSIONS Patients with a history and signs and symptoms of anaphylaxis Go to ANAPHYLAXIS Protocol. Patients who are systematically unwell Patients with Urticaria and angio oedema (deeper form of urticaria) ASSESSMENT When assessing a patient, you should: Diagnosis is made from a detailed history and examination of the individual. MANAGEMENT, TREATMENT AND ADVICE Patients with acute or chronic urticaria should be managed and treated as below: ACUTE URTICARIA - (CKS, 2007) Causes: Allergy Viral illness URTI Skin contact with stimulant chemicals, latex, cosmetics, plants, nettles Physical stimuli rubbed skin, extreme temperatures/water Localised or generalised Symptoms usually last no longer than 24 hours rash depending on but if remain see General practitioner causative agent Discuss with patient if a causative agent can be Small red/white raised identified areas 1-2 cm develop Advice patient to keep a rash diary if reoccurrence rapidly (wheals). Itch: advice patient consult community pharmacist May have erythema. OTC re: with non drowsy antihistamine such as Itchy Cetirizine or Loratidine If patient unable to purchase antihistamine supply Chlorphenamine IM or Oral as per PGD Advise the patient for itchy rash to consult community Pharmacist OTC re: Crotamiton cream.
CHRONIC URTICARIA - (CKS, 2007) Autoimmune reaction is thought to be associated with chronic urticaria such as internal allergies to food chronic infections e.g. sinusitis Localised or generalised rash Discuss with patient if a causative agent can depending on causative agent be identified Small red/white raised areas 1- Advice patient to keep a rash diary if 2 cm develop rapidly (wheals). reoccurrence May be erythema.
Itchy
Itch: advice patient consult community pharmacist re: with non drowsy antihistamine such as Cetirizine or Loratidine If symptoms severe contact GP
DISCHARGE AND FOLLOW UP In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital There is no need for the patient to have routine follow up. Advise the patient to see GP if symptoms worsen. Write and send routine letter of patient's attendance and treatment to GP. Children under 5 years must have a Health Visitor referral. All other discharge plans as per clinical decision by the nurse practitioner
UTI PROTOCOL
EXCLUSIONS Patients with urinary retention Patient with renal or ureteric colic The immunocompromised patient with urinary symptoms Pregnant women Adult male patients (symptoms may be due to other underlying conditions) Females over 65 years and Children under 5 years ASSESSMENT When assessing a patient, you should: Ask about recent surgery in perineal area, recent catheterisation, abdominal or back pain associated with urinary symptoms. Pregnancy - If there is a possibility that a patient may be pregnant, do a pregnancy test before continuing examination. Some medications e.g. cyclophosphamide, allopurinol, danazol, tiaprofenic acid (Surgam) may induce cystitis. In the elderly UTI may present as secondary incontinence, confusion, anorexia or pyrexia Adults may present with these symptoms: Urinary frequency, fever, haematuria, burning/stinging sensation, urgency, back pain, painful micturition, incontinence, suprapubic pain, cloudy or offensive urine. Children may present with these symptoms: Frequency, dysuria, dysfunctional voiding, changes to continence, abdominal pain, loin tenderness, fever, malaise, vomiting, haematuria and offensive or cloudy urine. MANAGEMENT Patients with a Urinary Tract Infection (UTI) should be managed as below: Take and record patients temperature If patient has a history of abdominal or back pain associated with urinary symptoms, examine abdomen and back for tenderness: Do a dipstick urinalysis: these are widely used to help with diagnosis of UTI, but it should be remembered that urine culture alone provides the definitive diagnosis. Urinalysis: Most urinary pathogens reduce nitrate to nitrite, thus a positive nitrite test is suggestive of bacturia but, a negative test does not rule out infection as not all pathogens produce nitrate reductase and frequent urination gives insufficient time for the enzyme to react. Leucocyte esterase is a marker for leucocytes and a positive test indicates pyuria, which suggests UTI. It can also indicate contamination of the specimen, so a positive test does not necessarily mean UTI. A negative Leucocyte Esterase (LE) test does not rule out UTI as pyuria is not always present in UTI. Blood and protein may be found in infected urine, but neither absence nor presence help
with diagnosis. Evidence from the literature suggests: If either nitrite or leucocyte esterase dipstick tests are positive diagnose UTI When both nitrate and leucocyte tests are negative and urine is clear indicates that the patient does not have a UTI. Always take an MSU to support decisions made on dipstick analysis - the nurse in charge is responsible for ensuring that specimens are sent and results actioned and forwarded to GP if applicable. Reception staff are responsible for ensuring results are filed with the casualty card as per policy. If patient has been unable to pass urine for 6 hours or more and has a tender distended abdomen If patient has severe intermittent (although maybe constant) pain in loin or groin and nausea and haematuria. If adult or child presents with any two of the symptoms above. Dip stick testing for leukocyte esterase and nitrite is diagnostically as useful as MC&S. If temperature is < 37oC and urinalysis excludes UTI If patient is pyrexial with absence of flank pain and urinalysis excludes UTI Go to referral pathway for urinary retention. Go to referral pathway for Renal /Ureteric Colic Go to treatment pathway for UTI
Follow treatment pathway for Cystitis Obtain MSU and follow treatment pathway for Cystitis
REFERRAL PATHWAYS Patients with Urinary symptoms listed that are outside the protocols should be referred as below: POSSIBLE PYELONEPHRITIS - (CKS, 2007) If adult or child has acute urinary Send an MSU for M C& S. symptoms with temperature >380C and associated flank pain and Refer to GP for the same day appointment or tenderness or if patient is if severe refer to Emergency Department. systematically unwell Supply analgesia according to pain score and as per PGD URINARY RETENTION - (CKS, 2007) Refer patient to Emergency Inform Emergency Department of referral Department Explain actions to patient RENAL OR URETERIC COLIC (CKS, 2007) If you suspect that the patient may Inform the Emergency Department of the have renal or ureteric colic refer to referral. Analgesia.
Explain action to patient and significant others Supply analgesia according to pain score and as per PGD
IMMUNOCOMPROMISED PATIENT WITH URINARY SYMPTOMS Refer patient to GP for same day appointment Send an MSU for M C & S and arrange for the results to be sent to the patients GP
SUSPECTED URINARY INFECTION IN A PATIENT WHO IS PREGNANT OR BREAST FEEDING (CKS, 2007) Send MSU for M C & S and arrange for the results to be sent to the patients GP Refer patient to GP for same day appointment REPEAT EPISODES OF URINARY SYMPTOMS & NEGATIVE MSU, OR MORE THAN 3 UTIs IN PAST 12 MONTHS Send an MSU for M C & S and arrange for the results to be sent to the patients GP Refer patient to their GP for next day appointment Advise patient to take OTC paracetamol for pain relief and maintain a good fluid intake until seen. ADULT MALE PATIENTS Refer to general practitioner
TREATMENT AND ADVICE Patients with urinary symptoms listed that are within the protocols should be treated as below: UNCOMPLICATED URINARY TRACT INFECTION IN OTHERWISE HEALTHY ADULT PATIENT (CKS, 2007) Presents with mild or any two of the symptoms as above with no vaginal irritation or discharge Urinalysis shows either nitrites or Send MSU for MC&S before commencing leukocyte esterase with associated treatment urinary symptoms Advise the patient to increase their oral fluid intake Advise the patient to take OTC paracetamol for pain relief and to reduce their temperature Treat with Trimethoprim as per PGD for 3 days. All women taking oral contraception should be advised to use extra precautions. Treat with Co -amoxicillin as per PGD In patients with known allergy or intolerance, previous recurrent resistance or prophylactic use of Trimethoprim, Advise patient to seek further advice from their GP if they are no better in 3 days, or if their symptoms worsen.
UNCOMPLICATED URINARY TRACT INFECTION IN OTHERWISE HEALTHY CHILD OVER 5 YEARS - (CKS, 2007 and NICE Guideline 54, 2010) If a child presents with specific urinary symptoms as above obtain a clean catch urine sample If both leukocyte esterase and Send MSU for MC&S nitrite are positive Advise the patient to increase their oral fluid intake Advise the patient to take OTC paracetamol for pain relief and to reduce their temperature Treat with Trimethoprim as per PGD for 3 days. All girls taking oral contraception should be advised to use extra precautions. If leukocyte esterase is negative Send MSU for MC&S and nitrite is positive Advise the patient to increase their oral fluid intake Advise the patient to take OTC paracetamol for pain relief and to reduce their temperature Treat with Trimethoprim as per PGD for 3 days. All girls taking oral contraception should be advised to use extra precautions. If leukocyte esterase is positive Send MSU for MC&S and nitrite negative Advise the patient to increase their oral fluid intake Advise the patient to take OTC paracetamol for pain relief and to reduce their temperature Do not start Trimethoprim unless clear clinical evidence of a UTI (e.g. obvious urinary symptoms) - treat with Trimethoprim as per PGD. All girls taking oral contraception should be advised to use extra precautions. If both leukocyte esterase and Send MSU for MC&S and results to GP nitrite negative ?Other cause for illness - refer to GP Treat with Amoxicillin as per PGD In patients with known allergy or intolerance, previous recurrent resistance or prophylactic use of Trimethoprim, Advise patient to seek further advice from their GP if they are no better in 3 days, or if their symptoms worsen. All children (under 16) who are treated for UTI should be advised to see their GP 5 - 7 days after their treatment, even if they feel better. CYSTITIS (CKS, 2007) Patient has acute Send an MSU for M C& S. urinary symptoms Advise the patient to take OTC paracetamol for pain relief. but dipstick Advise patients to increase their oral fluid intake. urinalysis is Some patients may find OTC alkalising agents (e.g. negative potassium citrate) helpful in symptom control, although there is no evidence of their efficacy.
Advise patients that most episodes of cystitis get better after 2-3 days, but if they are no better, or if their symptoms get worse, they should return to their GP for further assessment. PATIENT FOLLOW UP If symptoms not resolving after 3-4 days or if symptoms deteriorate then they should contact their General Practitioner Patients whose symptoms persist Should seek assessment by their General over two weeks Practitioner Men and children with urinary Should always be followed up by their General tract infection Practitioner, as they may need further investigation. For patients treated with antibiotics.
DISCHARGE & DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital Write and send routine letter of patient's attendance and treatment to GP. Children under 5 years must have a Health Visitor referral. All other discharge plans as per clinical decision by the nurse practitioner
Mosaic warts
Flat-topped papules with minimal scaling. Skin-coloured, light brown, or pigmented rashes are often not recognised as planar warts. Sharply defined, rough, keratotic lesion with a smooth collar of thickened skin. Punctuate black dots (thrombosed capillaries) are seen if the surface is shaved away. Occur when palmar or plantar warts coalesce into larger plaques Small, pink- white, firm, round and smooth wart like lumps on the skin
Single or multiple, usually less than 20. Individually can grow from 1 mm to 1 cm in size, but may coalesce to form mosaic warts. Usually one or a few in an area, but often with nearby small individual plantar warts. Often in clusters but no more than 20. Not contagious
Molluscum Contagiosum
MANAGEMENT AND ADVICE Patients with symptoms of a wart or verruca should be managed as below: Children with warts or verrucas do not have to be excluded from sports or swimming. However advice to reduce the risk of transmission by: Cover the wart with a waterproof plaster when swimming. Wear flip-flops in communal showers. Avoid sharing shoes, socks, or towels. Avoid scratching lesions. Avoid biting nails or sucking fingers that have warts. Keep feet dry and changing socks daily
No treatment is usually necessary as spontaneous resolution is common but can take up to two (2) years. Duct tape can be used to cover in small children and any feet warts/verrucas. However if the wart is causing problems, pain or is unsightly then treatment is required advise patient consult community pharmacist re: OTC topical salicylic acid (Salactol Wart Paint or Gel) or equivalent.
DISCHARGE ADVICE& DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital Ensure patient has a wart and verruca information sheet. Write and send routine letter of patient's attendance to GP. Children under 5 years must have a Health Visitor referral. All other discharge plans as per clinical decision by the nurse practitioner
BITES - HUMAN/ANIMAL Clean affected area (vigorous wound cleansing is required -Irrigation and local anaesthetic maybe required) Apply suitable dressing; in accordance with wound dressing management protocol Patients with deep facial bites and those Refer to ED.
that involve underlying structures Patients with deep bites with foreign body that is not easily removed - e.g. tooth For human bites
Refer to ED Thorough deep cleaning using Providine iodine as per PGD, ensure flushed/irrigated afterwards with saline. Supply Co-amoxiclav as per PGD Supply Doxycycline and Metronidazole TTA packs (See PGDs) Thorough deep cleaning using Providine iodine as per PGD, ensure flushed/irrigated afterwards with saline. Treat with Co-amoxiclav as per PGD if deep and not draining. Supply Doxycycline and Metronidazole TTA packs. If under 12 years refer to microbiologist for advice. Treat in accordance with Tetanus protocol. Supply appropriate antibiotic cover as above
For patients who are allergic to penicillin with human bites For all other bites such as: Primate, cat bites, penetrating dog bites and all crushing bites e.g. Camel, horse, cow, should have antibiotic cover. For patients who are allergic to penicillin with animal bites Assess Tetanus Immunology Status If signs of infection present, and patient has not commenced antibiotic therapy
If antibiotics have been supplied and signs Refer patient to ED as patient may require of infection not improving/worse I.V. antibiotics. All bite wounds must be reviewed after 48 hours within the MIU NB. Wounds over knuckles after a fight are often human bites and may be intraarticular injuries MINOR BURNS AND SCALDS Specific assessment - Examine the wound carefully with emphasis on: Position, depth and size of burn- chart Causative agent Sensation and movement Time lapsed since injury Associated injuries A simple sketch of the burn position is advisable The nurse practitioner should seek immediate Burns (partial thickness) that cover more than 5% of the adult patient's body surface medical advice: area or 1% of the child's body surface Assess and Refer to ED senior or plastics. area. Burns involving the airway Burns to the face, genitalia or over a joint Burns or scalds that are circumferential of Refer to Plastics via Derriford Hospital any limb or torso - refer to plastics. switchboard - children may need referral to Frenchay Hospital Bristol - see poster in unit Electrical or chemical burns Refer to ED Deep Dermal: Mottled, white or deep red, Do not apply creams and do not apply waxy dry surface, diminished sensation, Flamazine to any burn being referred to the
slower capillary refill, less blanching with pressure, less exudate and blisters. Slightly painful-not able to discriminate between sharp and blunt pin-prick test. May heal within 30 days or more, often grafted due to high risk severe hypertrophic scarring and full thickness burns Full Thickness: White, brown/tan or black or cherry red, leathery, dry and painless, may have visible thrombosed veins, no capillary refill. Requires grafting to heal. Scarring influenced by early excision and grafting Superficial: Bright pink or red, dry, intact, with/without oedema, painful, blanches with pressure with rapid capillary refill. Heals spontaneously within 3/7 days with minimal intervention. No scarring Partial thickness: burns over 5% surface body area in adults and 3% in children Red, blistered, swollen/pink and moist under the blisters, brisk capillary refill. Heals within 10/21 days. Some scarring depending on patients genetic disposition covering less than 5% surface body area in adults and 3% in children
Refer to ED
www.burnsurgery.com/betaweb/modules/burnwound/part_v.htm
Remove burning agent If new burn/scald cool down - run area under lukewarm water for 15 minutes or apply cold water soaked pads. Clean the wound with saline (or lukewarm tap water on initial presentation) Leave blister intact wherever possible to reduce the risk if infection, large blisters that are likely to burst or are in an awkward position may require deroofing. Remove any loose or dead tissue. Supply adequate pain relief depending on patients pain score as per analgesia PGD If anti-tetanus therapy required, treat in accordance with Tetanus protocol Dress burn according to current good practice i.e. Paraffin gauze (use sufficient amount to prevent drying out) or Siliconecoated nylon dressings Semi-permeable film (Opsite or Tegaderm). Dressings: Face Vaseline/liquid paraffin Small burns Mepitel, jelonet or Atrauman Large burns (pending transfer) clingfilm Hands liquid paraffin in burn bag. Take wound swab. Consider an antibacterial cream and apply Flamazine as per PGD Supply antibiotic as per Flucloxacillin PGD Supply adequate pain relief depending on patients pain score as per analgesia PGD
Infected burns/scolds
FOREIGN BODIES IN WOUNDS Specific Assessment - Examine the wound carefully with emphasis on: History of shattered or stood on glass History of occupational fibres High speed metal fragments Wound not healing Visible or palpable FB Refer to ED If poor cooperation - especially children FB near or potentially near vital structures Large FB Unable to find or remove Glass Explore wound may need to use magnifying goggles Wood/grit/other FB If easily visible or palpable remove FB with Metal splinter forceps, clean and dress Fish hook Xray to detect metal, glass or large pieces Fibre glass of grit Remove FB or Fish hook (push barb through and cut off with pliers, retract smooth part of the hook) under local anaesthetic per Lidocaine PGD if not contraindicated Document removal and show patient. If FB visible on xray but cannot be seen using magnifying goggles or felt assess degree of difficulty of removal, refer to MIU or Clinic 1for follow up. Fibreglass FB are very difficult to locate and are fragile, therefore, refer patient to ED for management. HIGH INJECTION WOUNDS Caused by high pressure air lines, grease guns, moulding injectors, paint guns, diesel fuel jets Wound does not reflect severity Xray if radio opaque material injected Pain in area of injection If substances injected contact Poisons unit Check tension in surrounding tissues for specific problems and manufacturers May have palpable material spreading advice from wound Supply analgesia as per pain score and as May have altered circulation and or per PGD sensation Temporary dressing and elevate limb Refer to ED for exploration of wound PULP INJURIES TO FINGERS The wound is a severe crush injury The wound contains fragments of foreign material that are not easily removed There is significant bony involvement
Refer to ED
There is neurovascular injury There is significant skin loss There is clear involvement of the nail bed Crush injury
Partial amputation
Burst laceration
Xray if bony tenderness to exclude bony injury - if # follow # management protocol Clean with saline Dress according to current best practice generally soft yellow paraffin Review in 2-3 days dressing clinic Xray Analgesia as per PGD Cover with temporary dressing/elevate Refer to ED Clean Steristrip - may need to suture to increase tension Inadine dressing 2-3 days Review in Dressing clinic Refer to ED
PUNCTURE WOUNDS If suspicion of remaining foreign body If there is pain to underlying structures or area If there is any tension in surrounding tissues Wound evident - e.g. trod on a nail
Assess patients pain-local anaesthetic may be required prior to treatment (see Lidocaine PGD) Deep clean wound with Povidone iodine solution as per PGD, ensure flushed/irrigated afterwards with saline. Dress the wound according to current good practice These are Tetanus prone wounds. Check Tetanus status and administer ATT if required as per Human Tetanus Immunoglobulin or Immunisation PGD If the wound is contaminated or signs of infection present, antibiotics will be required, supply TTA pack in accordance with Flucloxacillin PGD. If patient allergic to penicillin see Erythromycin PGD. If needlestick injury, Hepatitis B/HIV may be a risk, refer to PHT/PCH inoculation protocol (the patient will require transfer to the local ED) Written an verbal wound care advice
STINGS- INSECT & FISH Extensive swelling, urticaria, erythema, lymphangitis/cellulitis. If the sting involves the patient's eyes or mouth Angio-oedema, wheeze or respiratory distress History of previous severe reaction or known allergy Visible sting/bite Localised and in varying degrees: redness, itchiness, warmth and swelling
Refer to ED
If patient demonstrates signs of anaphylaxis-treat in accordance with Anaphylaxis protocol. Remove sting if still present. Apply cold compress If anti-Tetanus therapy required-treat in accordance with Tetanus protocol For weaver fish sting soak affected limb in hot water (approximately 40C or as hot as can be tolerated for 30 minutes) For mild urticaria treat with Chlorphenamine IM or Oral as per PGD For mildly red, itchy local insect bite reaction treat with either Crotamiton cream OTC or equivalent if very red and itchy insect bite local reaction treat with Hydrocortisone 1% OTC or equivalent Localised infected insect bite/stings - local erythema, heat, oedema and tenderness but no ascending lymphangitis treat with Flucloxacillin as per PGD. If patient allergic to penicillin see Erythromycin as per PGD. Review the next day.
SPECIFIC LACERATION MANAGEMENT Ear lacerations Examine and clean If cartilage involved refer to ENT Suture and or Steristrip under local anaesthetic Lidocaine as per PGD If anti-Tetanus therapy required-treat in accordance with Tetanus protocol Wound care advice Removal of sutures/steristrips in 5 days Subperichondrial haematoma If large refer to ED for aspiration (leading to cauliflower ear) If small apply pressure dressing and review 1 day (refer if no improvement) Split ear lobe If new Suture or Steristrip under local anaesthetic Lidocaine as per PGD If earlobe edges are healed refer to GP as will need to
Intra - oral/tongue/gum
Pre-tibial
be reopened If large or actively bleeding seek advice from dentist/max-fax Usually heal well see GP if concerns Strict oral toilet 5 days Soft cool diet If deep or large refer to ED Only steristrip/suture lacerations competent to do so, but consider cosmetic result - refer to ED if not Consider history and clinical examination - ?NAI refer to ED if appropriate If laceration involves the Vermilion border - refer to ED If not involving vermilion border Suture or Steristrip under local anaesthetic Lidocaine as per PGD Suturing should be avoided in most pre-tibial lacerations Flap should be lifted (local anaesthetic may be required see Lidocaine PGD) and all clots evacuated and any devitalised tissue removed before flap replaced flat Close with self-adhesive strips Cover with a non-adherent dressing Padding with a secondary dressing such as gamgee or surgipad (this will also help in protecting the wound from any knocks) If indicated, a double layer of elasticated tubular bandage (tubigrip) may be applied, from toe to knee. Advise patient not to stand for long periods, to rest with the limb elevated and to use regular ankle and leg exercises. Initial follow-up 2-3 days in MIU dressing clinic. Further follow-up appointments by their practice nurse.
WOUND CLOSURE The following wounds should be referred to ED. Wounds with suspected damage to muscle, tendon, nerve or large blood vessels Wounds which are infected or have a high risk of becoming infected Wounds that were sustained more than 12 hours prior to attendance. A good cosmetic result cannot be obtained on a distressed child, consider referral. Tissue Adhesive Clean wound with saline Not to be used to close Explore wound - may need to use magnifying lacerations: goggles over joints Approximate wound edges Drop tissue adhesive on approximated wound Deep and or gapping wounds Hold in position for 30-60 seconds Close to eyes Wound care advice 5-7 days Moist/wet areas
Steristrips
Sutures
Clean wound with saline Explore wound - may need to use magnifying goggles Approximate wound edges Ensure haemostasis before applying steristrips Place steristrips at right angles across the wound - without tension Can use tissue adhesive if tension required Wound care advice 5-7 days Obtain written consent and complete pre surgical procedure checklist Clean wound with saline Select appropriate suture material and size: Face 5/0 or 6/0 Scalp 3/0 or 4/0 Hands - if appropriate and feet 4/0 Legs and Trunk 3/0 Suture or Steristrip under local anaesthetic Lidocaine as per PGD Apply current best practice dressing dependent on area of wound and occupation of patient Elevate if upper limb Written and verbal wound care advice Removal to MIU or Practice nurse Face 3-5 days Scalp 5-7 days Hands, arms and legs 7-14 days Over joint 14 -21 days
DRESSINGS Basic wound contact dressing - to provide wound protection from the environment dry non exudating wounds e.g. post suturing/steristrips Absorbent dressings for lightly exuding wounds Protection dressing for non exuding wounds e.g. post suturing Alginate dressing for moderately exudating wounds e.g. cavity, deep dermal or sloughy wounds Foam dressing for light - moderate exuding wounds Hydrocolloid dressing to create moist conditions enabling healing for exuding wounds e.g. necrotic wounds Low adherent paraffin gauze primary dressing allowing exudates to pass
N A ultra
Cosmopore Hydrofilm Kaltostat or Sorbsan Lyofoam Hydrocoll/Hydrogel Jelonet or soft yellow paraffin
through onto secondary dressing - needs to be changed every two days - e.g. burns, abrasions or partial thickness wounds Long lasting antiseptic - manages infection Inadine by bacteria, protozoal, and fungal organisms - not suitable for dry or necrotic wounds Non adhesive primary dressing that allows Atrauman exudates to pass mesh to be absorbed by secondary dressing e.g. open wounds, abrasions, post steristrips Infected burns Flamazine cream Abrasions to remove grit 24 hours only Removing stubborn dry scabs When managing wounds consideration should also include location of wound, age of patient and employment and avoid compromising blood supply, avoid tension, and avoid cavity formation. MANAGEMENT OF INFECTED WOUNDS If presents with Cellulitis, lymphangitis or an abscess. May have ascending lymphangitis and palpable lymph nodes Patient presents with localised: Swelling Redness Tenderness Hot to touch Pus or discharge Mark area. Record observations. Refer to ED Mark area of localised inflammation Record Temperature Supply with Flucloxacillin as per PGD If allergic to penicillin supply Erythromycin as per PGD Follow up in 24 hours in MIU dressing clinic If infection due to bite follow Bite management
DISCHARGE PLAN & DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital All patients treated for wounds within the Minor Injuries Unit should leave the department with the following information: Written instructions on wound/dressing or burn care and follow up care Guidelines on action to take if signs and symptoms of infection MIU follow up appointment with date and time recorded on clinical notes Advise on when to arrange follow-up with Practice nurse or GP as pathway states Write and send routine letter of patient's attendance and treatment to GP. Children under 5 years must have a Health Visitor referral. All other discharge plans as per clinical decision by the nurse practitioner
When assessing a patient for Tetanus status you should: Ascertain the Tetanus Immunology Status of all patients who have suffered a breach of their skin integrity, regardless of cause. The MIU will administer the appropriate tetanus prophylaxis, to these patients, as currently recommended by Department of Health Immunisation against Infectious Disease. *Tetanus-prone wounds include: Wounds or burns that require surgical intervention (e.g. wound edges require surgical debriding) and when that surgical treatment is delayed for more than six hours. Wounds or burns that show a significant degree of devitalised tissue or a puncture-type injury particularly in contact with soil. Wounds containing foreign bodies. Compound fractures. Wounds or burns in patients who have systemic sepsis. Wounds involving materials from farm animals and horses. If the wound, burn or injury fulfils the above criteria and is considered to be high risk, human tetanus immunoglobulin should be given for immediate protection, irrespective of the tetanus immunisation history. High risk is regarded as heavy contamination with material likely to contain tetanus spores and or extensive devitalised tissue. Injecting drug users may be at risk from tetanus-contaminated illicit drugs, especially when they have sites of focal infection. Patients who are immunosuppressed should be managed as if they were incompletely immunised. For those whose immunisation status is uncertain, and individuals born before 1941 who may not have been immunised in infancy, a full course of immunisation is likely to be required.
Reference: HPA - Immunisation Handbook - Feb 2010 IMMUNISATION CLEAN WOUND TETANUS-PRONE WOUND STATUS Vaccine Vaccine Human tetanus immunoglobuli n Fully immunised, None required None required Only if high risk i.e. has received a (see above*) total of five doses of vaccine at appropriate intervals Primary None required None required Only if high risk immunisation (unless next dose (unless next dose (see above*) complete, boosters due soon and due soon and incomplete but up convenient to give convenient to give to date now) now) A reinforcing dose A reinforcing dose Yes: one dose of Primary human tetanus of vaccine and of vaccine and immunisation immunoglobulin further doses as further doses as incomplete or in a different site required to required to boosters not up to complete the complete the date recommended recommended schedule (to schedule (to ensure future ensure future immunity) immunity) Yes: one dose of An immediate An immediate Not immunised or human tetanus dose of vaccine immunisation status dose of vaccine followed, if records followed, if records immunoglobulin not known or in a different site confirm this is confirm this is uncertain needed, by needed, by completion of a full completion of a full 5-dose course to 5-dose course to ensure future ensure future immunity immunity COMBINED TETANUS VACCINES In August 2004, following recommendations from the Joint Committee on vaccination and Immunisation (JCVI) tetanus vaccine will only be available as part of a combined product as below: Pediacel (DTaP/IPV/Hib), For primary immunisation Repevax (dTaP/IPV) Diphtheria/tetanus/acellular pertussis/inactivated polio vaccine For reinforcing doses in children under 10 years of age Revaxis (Td/IPV) Tetanus/diphtheria/inactivated polio vaccine For teenage boosting and for primary immunisation and reinforcing doses in adults and children over 10 years of age
(Combined Tetanus Vaccines page 3 of 3)
Recommended frequency of Primary and Reinforcing Immunisations. Age Group Infants and Children under 10 years of age Primary Course Requirements The primary course consists of three doses with an interval of one month between each dose. Pediacel (DTaP/IPV/Hib) is recommended for all infants from two months and up to 10 years of age. If the primary course is interrupted it should be resumed but not repeated, allowing an interval of one month between the remaining doses. Children aged 10 years and over and adults. The primary course consists of three doses with an interval of one month between each dose. Revaxis (Td/IPV) is recommended for all individuals aged 10 years and over. If the primary course is interrupted it should be resumed but not repeated, allowing an interval of one month between the remaining doses. Age Group Infants and Children under 10 years of age Reinforcing Requirements Should, ideally receive the first booster three years after completion of the primary course. Repevax (dTaP/IPV) should be used to produce a satisfactory booster immune response. Should have the first booster of Revaxis (Td/IPV) Should, ideally receive the second booster of Revaxis (Td/IPV) 10 years after the first booster dose. When the previous doses have been delayed, the second booster should be given at the school session provided a minimum of five years have lapsed between the first and second boosters.
Children aged 10 years and over and adults: who have only had three doses with the last dose at least five years ago Children aged 10 years and over and adults: who have completed the primary course and received the first booster
DOCUMENTATION In accordance with MIU documentation protocol. Ensure that a copy of all documentation accompany all patients that are transferred to the local hospital
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8. Associated Documentation
Equality Rapid Impact Assessment Tool Audit tool for the review and approval of handbook of clinical protocols Plan for dissemination of handbook of clinical protocols Staff distribution signature list for the handbook of clinical protocols
9.
Written by: Name: Linda Green Clinical Lead Signature ________________________ Date ____________________________
Name: Annie Tyrie MIU Service Manager Signature ________________________ Date ____________________________
Independent Check and Approval Medical Practitioner Name: Mr. Iain Grant Signature ________________________ Date ____________________________
Final Approval on behalf of Plymouth Community Healthcare Final Approval for use: Service Director Name: Michelle Thomas Signature ________________________ Date ___________________________
APPENDIX A
On completion of this record, this sheet will be kept by the line manager and become part of the training record.
Signature
Date
Appendix B : ABBREVIATIONS THAT MAY BE USED: 1/7 One day 1/52 1/12 1st aid A+ED AED APB APL / EPB AVPU APM ASB ATTB HATI Approx BP BAS BD BICA cm Cap Refill (CR) (CRT) CC&SH C&S DIPJ DPP (DP) DTG DVT ECG ED EDM EI ENT EPL FB One week One month First aid Accident and Emergency (Emergency Department) Advisory External Debfibrillation Abductor Pollicis Brevis Abductor Pollicis Longus Alert, Voice Response, Pain, Unresponsive Abductor Pollicis Muscle Anatomical snuff box Anti tetanus toxoid booster Human anti tetanus immunoglobulin Approximately Blood pressure Broad arm sling Twice daily Basic Information & Contact Assessment Centimetre Capillary refill Community Contraception &Sexual Health Culture and Sensitivity Distal interphalangeal joint Dorsalis Pedis pulse Double tubigrip Deep Vein Thrombosis Electrocardiogram Extensor Digitorum Extensor Digitorum Minimi Extensor Indicus Ear, Nose and Throat Extensor Pollicis Longus Foreign body
FDP FDS FPB FPL FRAT FROM GCS GP HAS HCA HCP IUD (i/c) IPJ KOd LAT MAL (LM) MCPJ MC MC&S MP (IP) MT MTPJ mm MED MAL (MM) NAD NP NWB O/E OTC OP P PE PIPJ PEARL
Flexor Digitorum Profundus Flexor Digitorum Superficialis Flexor Pollicis Brevis Flexor Pollicis Longus Falls Risk Assessment Tool Full range of movements Glasgow coma scale General Practitioner High arm sling Healthcare Assistant Healthcare Professional Intrauterine Device With Interphalangeal joint Knocked out Lateral malleolus Metacarpo phalangeal joint Metacarpal Microscopic Culture and Sensitivity Middle (Intermediate) Phalanx Metatarsal Metatarsal phalangeal joint Millimetres Medial malleolus Nothing abnormal detected Nurse Practitioner Non weight bearing On examination Over the Counter medicines Opponens Pollicis Pulse Pulmonary Embolus Proximal interphalangeal joint Pupils equal and react to light
PHT Physio POP PP QDS RCL R.R ROM PMH PWB ROS RICE R/V SHO T/temp TDS TOI. TP (DP) UCL UK UPSI VA W/B # + ++ +++ < >
Plymouth Hospital Trust Physiotherapy Plaster of Paris Proximal Phalanx Four times a day Radial Collateral Ligament Respiration rate Range of movements Treatment Past medical history Partial weight bearing Removal of sutures Rest, ice, compression, elevation Review Senior House Officer Temperature Three times a day Time of injury Terminal (Distal) Phalanx Ulna Collateral Ligament United Kingdom Unprotected Sexual Intercourse Visual acuity Weight bearing Fracture A little Moderate Large Less than More than Diagnosis Tested and found to be normal Decreased
Increased
APPENDIX C Patient Information Leaflets held in the MIU. Acute Knee Problems Ankle Injury (Adult and Child) Back Care Bites and Stings Calf Injury Care of Plasters Cervical Collar Chest Injury Corneal Abrasion Diarrhoea and Vomiting or Constipation in Infants and Children Fractured Clavicle Hand/Wrist Problems Head Injury Adult and Child High temperature (Child) Mallet Finger Pulled Elbow (Child) Scaphoid Fractures Sunburn Prevention for Children Use of Crutches and Walking Sticks Whiplash Wounds and Burns Wound Care
APPENDIX D. Algorithm care pathway. Patient booked in to MIU Patient triaged (using SOAPE). NO
Is the patients condition/illness within clinical protocols.
YES
NO YES
Assessment of patient by appropriately trained nurse. Refer patient to most appropriate facility i.e. * Local A&E, with documentation. * GP, with MIU letter * Local Pharmacist
AMT September 05
APPENDIX E
Risk Stratification
Complete the Risk Assessment form to risk stratify the patient. Keep the completed form with the patients notes (copy with our notes). Those who score 3 or above and have no contraindications should be started on Enoxaparin 40mg s/c daily (depending on creatinine clearance see below). Contraindications: Have a known bleeding disorder or thrombocytopenia (platelets <50x109 /l) Stroke or risk of central nervous system bleeding e.g. head injury or previous subarachnoid haemorrhage GI bleed in previous 4 months Aortic aneurysm, or pericarditis Previous history of heparin induced thrombocytopenia Receiving treatment with Enoxaparin (Clexane) or Warfarin already Enoxaparin should be reduced to 20mg daily in patients with creatinine clearance <30ml/min (creat >200)
Management
Baseline FBC and U&Es should be undertaken on all patients who are prescribed Enoxaparin. Write on blood form reason for request for the detection of HIT. Document risk stratification on ED notes. On the discharge letter to GP state the following: