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Plymouth Community Healthcare CIC

Minor Injury Unit Handbook of clinical protocols Version 3.1

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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Minor Injury Unit Handbook of clinical protocols Version 3.1.

Reader Information and Asset Registration


Title Information Asset Register Number Rights of Access Type of Formal Paper Category Format Language Subject Document Purpose and Description Author Ratification Date and Group Publication Date Review Date and Frequency of Review Disposal Date Minor Injury Unit Handbook of clinical protocols 588 Limited Protocols Clinical Word Document English Protocols Clinical protocols for nurse practitioners to work within in conjunction with Patient Group Directives MIU Manager and Senior Nurse Practitioner SWLT 28th April 2011. Policy Ratification Group. 09/10/2012 09/10/2014 The Policy Ratification Group will retain an e-signed copy for the database in accordance with the Retention and Disposal Schedule; all previous copies will be destroyed. Senior Nurse Practitioner Minor Injury Unit, Cumberland Centre. Band 6 and 7 Nurse Practitioners, Assistant Practitioner Unregistered Healthcare Assistants Minor Injury Unit, Cumberland Centre. Electronic: Plymouth Healthnet and PCH website Written: Upon request to the Policy Ratification Secretary on 01752 435104.

Job Title of Person Responsible for Review Target Audience

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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Minor Injury Unit Handbook of clinical protocols Version 3.1.

Tel: Fax: Publisher: (for externally produced information)

0845 155 8085 01752 272522 (LCC Reception)

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

Protocols reviewed and updated

V 2:1

Updated

March 2009.

2:2

Reviewed and updated

August 2010

2:3 3 3.1 Ratified Updated

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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Minor Injury Unit Handbook of clinical protocols Version 3.1.

HANDBOOK OF CLINICAL PROTOCOLS


1. Introduction
The clinical protocols enable the Minor Injury Unit (MIU) Nurse Practitioners (NP) to assess, treat, discharge and transfer patients that attend the unit with a particular minor injury or minor illness that are not excluded from the individual protocols. These clinical protocols are not static; they will be developed as the nurse practitioners become more confident and competent and will be reviewed two yearly by the team and with consultation with relevant healthcare professionals.

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:

Diagnosis: Treatment: Medication:

Disposal to include:

Signature: Coding:

Computer data coding:

See Appendix B for agreed abbreviations that can be used

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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

Airway Breathing Circulation Disability Exposure

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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ASTHMA: - ADULTS AND CHILDREN


IMPORTANT: Patients failing to respond adequately to the treatment given at any time, requires immediate referral to Plymouth Hospital Trust ED. ASSESSMENT When assessing a patient, you should: Record type and duration of asthmatic symptoms and if any treatment has been started. Record heart and respiratory rate and oxygen saturation using pulse oximetry (SpO2) Record peak expiratory flow (PEFR) if patient is old enough to comply as is not helpful in a patient under five years of age. Use the best of three recordings of this test to grade the severity of the attack: moderate = 50-75% of normal; Acute = 33-50% of normal and life threatening = <33%. Check for the presence of a wheeze - it may not be asthma. Assess if any possible trigger factors e.g. recent Upper respiratory infection. Assess if one or more adverse psychological factors/severe factors present LEVEL OF SEVERITY - as defined by British Thoracic Society 2009 LIFE THREATENING ASTHMA Patients are deemed to be experiencing life threatening asthma if they display the symptoms listed below: Adults PEF < 33% best or predicted Bradycardia, hypotension, dysrthythmia or exhaustion Agitation or reduced level of consciousness, confusion, Feeble respiratory effort, Silent Chest, cyanosis, exhausted SpO <92% Children >5 PEF < 33% best or predicted SpO < 94% Poor or feeble respiratory effort Agitation, confused, Cyanosis, Altered consciousness, Silent Chest Children 2-5 SpO < 94% Poor or feeble respiratory effort Agitation, Cyanosis, Altered consciousness, Silent Chest

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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Speech normal Respiration <25 breaths/min Pulse < 110 beats/min

or best Able to talk Respiratory < 30/min Pulse < 120/min

Feeding/speech normal Respiration < 50 breaths/min Pulse < 130 beats/min

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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BOILS, CARBUNCLES, FOLLICULTIS, PARONYCHIA AND STAPHLOCOCCAL WHITLOW PROTOCOL


EXCLUSIONS Patients with subungual abscesses and carbuncles with multiple heads, Anthrax (haemorrhagic crusts and vesticular margins) and patients with Orf (localised punched out, circular crusted lesions often found on the hands of patients who work with animal carcasses or uncured hides) and patients excluded from Fusidic Acid PGD

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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CALF PROBLEMS and INJURIES


EXCLUSIONS Patients presenting with any evidence of an injury/trauma to the Achilles tendon i.e. positive Simmonds test, pain / tenderness below muscle-tendon junction (lower third of calf), palpable gap in tendon, or the inability to stand on tip-toes. Patients presenting with any muscle wasting, varicose veins or ischaemia thrombophlebitis. ASSESSMENT When assessing a patient, you should: Inform parent/carer of the role of the nurse practitioner and obtain consent for treatment. MANAGEMENT, TREATMENT AND ADVICE PATIENTS WITH SYMPTOMS SUGGESTIVE OF A DEEP VEIN THROMBOSIS No history of injury. Subacute onset Refer the Patient to DVT Clinic via Redness, warmth, calf or whole leg switchboard or ED if Wells Scoring swelling, discoloured or pale leg, dilated suggests moderate or severe risk, and/or peripheral veins, increased pitting oedema no alterative disorders in the affected leg, dull ache in calf Follow care pathway for DVT Score Wells Clinical Prediction Rule as below Wells Clinical Prediction Rule for Deep Vein Thrombosis: Points Present Active Cancer (on-going treatment or diagnosed within 6/12 or 1 palliative care) Paralysis, paresis, recent plaster cast immobilisation of lower 1 extremity Recently bedridden for more than 3 days and/or major surgery < 1 1 month Localised tenderness along distribution of deep veins 1 Entire leg swollen 1 Calf swelling of greater than 3cm compared with asymptomatic 1 leg measured at 10cm below tibial tuberosity Pitting oedema (greater in symptomatic leg) 1 Collateral superficial veins (non-varicose) 1 Alternative diagnosis as likely as or more likely than DVT -2 Reference: Wells et al (1997) Wells score for deep vein TOTAL thrombosis. Lancet; 350:1795-98 Also consider the risk factors of oral contraception and long distance air travel Low risk 0: 3% probability DVT Moderate risk 1-2: 17% probability DVT High risk 3 or more: 75% probability of DVT Patients without a diagnosis of a DVT should be managed as below: NON- TRAUMA CALF PAIN - CRAMP Sudden onset of pain to calf following exercise.

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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CHEST INJURY (MUSCULOSKELETAL)


EXCLUSIONS Patients complaining of musculoskeletal chest pain where there is little/no evidence of direct trauma to the chest. Patients complaining of crushing chest pain, pleuritic pain without injury, recent onset of pain or discomfort of suspected cardiac origin. This may be accompanied with any of the following clinical signs Severe Shortness of breath / difficulty breathing Nausea and/or Vomiting. Haemoptysis Sweating / pallor / weakness Pain or altered sensation radiating to arms, neck or jaw. FOR THESE PATIENTS REFER TO THE CHEST PAIN OF RECENT ONSET OR DISCOMFORT OF SUSPECTED CARDIAC ORIGIN PROTOCOL PATIENTS WHO HAVE SUFFERED SIGNIFICANT INJURY MUST BE REFERRED TO A DOCTOR OR PLYMOUTH HOSPITAL TRUST ED PATIENTS ASSESSED AND FOUND TO A HAVE FEATURES OF A MEDICAL CONDITION SUCH AS PNEUMOTHORAX, PNEUMONIA OR PLEURITIC TYPE CHEST PAIN MUST BE REFERRED TO A DOCTOR. ASSESSMENT When assessing a patient, you should: Assess whether the pain is of sudden onset, well localised with tenderness on palpation and directly associated with a history of injury. MANAGEMENT Patients with moderate-severe musculoskeletal chest pain should be managed as below: Moderate-severe difficulty in breathing Wheezing Use of accessory muscles Fainting Difficulty swallowing and talking Significant bruising and/or swelling Unequal chest movement Haemoptysis Increased pulse and decrease in BP Record temperature, pulse, BP Pulse Oximetry and respiration rate Look, listen and feel chest Supply appropriate analgesia as per PGD Refer patient to ED for medical opinion may need ambulance or contract taxi.

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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Swelling to chest wall

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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DAMAGED OR MISSING TEETH


EXCLUSIONS Patients with chipped teeth and crowns that have become dislodged should be redirected to their dentist. Patients with tooth fractures that involve the pulp present with a small area of bleeding and are he area is sensitive. These patients should be referred to their dentist. If the patient is not registered with a dental practitioner and has difficulty obtaining an emergency appointment, then contact the on call Maxillofacial surgeon at PHT for advice. Patients with mobile teeth after trauma need to be stabilised as soon as possible. Advise the patient to avoid manipulating the tooth, these patients should be referred to their dentist. If the patient is not registered with a dental practitioner and has difficulty obtaining an emergency appointment, then contact the on call Maxillofacial surgeon at PHT for advice. AVULSED TEETH Avulsed primary teeth are not suitable for re-implantation. A history of rheumatic fever, valvular heart disease, or immunosuppressive treatment are relative contraindications to re-implantation. Refer to patients dentist or on call Maxillofacial surgeon for advice. Avulsed permanent teeth should be re-implanted immediately, to optimise the prognosis. ASSESSMENT When assessing a patient, you should Inform patient of role of nurse practitioner and obtain consent for treatment MANAGEMENT AND DISCHARGE PLAN Patients with damaged or missing teeth should be managed as below: Advise the patient not to wash the tooth. Advise the patient that milk is the best fluid to put the tooth in and bring to MIU or dentist. The best chance of success lies with early re-implantation, within first six hrs. Handle the tooth only to re-implant it, holding it by the crown. Position the tooth correctly then replace it within the socket using firm pressure (it is important to replace the tooth the correct way) Ask the patient to bite together and hold the tooth in place with the fingers, if necessary. Ensure tetanus prophylaxis up to date. Refer immediately to patients dental practitioner but if unavailable contact the on call Maxillofacial surgeon for advice. If the patient does not have a dentist advise them to contact the Dental Helpline Monday 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 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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EAR ACHE PROTOCOL


EXCLUSIONS Patient presents with earache or ear discharge associated with history of head trauma, go to Head Injury Protocol. Patient who is Immunocompromised and has an increased risk of or suspected of acute complications, Severe Otitis Externa, Mastoiditis, meningitis, facial paralysis: For these patients follow the appropriate referral advice within this protocol. Children with re-occurring ear infections (3 or more episodes in 6/12) must be referred to a medical practitioner. ASSESSMENT When assessing a patient you should: Ask the patient if they have experienced any of the following; Noise exposure, cotton bud use, recent flying, recent syringing, recent swimming, and recent diving Patients may present with these symptoms: Pain, earache, pyrexia/fever, coryza, malaise, dizziness, itch, discharge, hearing change, swelling. MANAGEMENT Patients with ear ache should be managed as below: Measure and record temperature, pulse and respiration rate Examine external auditory meatus and pinna for swelling, tenderness or lesions. Include palpation of tragus Examine ear canal for evidence of swelling, inflammation, foreign bodies and note nature and amount of any discharge. Visualise ear drum noting colour, translucency and any bulging / retraction of tympanic membrane and presence of fluid levels REFERRAL PATHWAYS Patients with suspected acute complications outside of the protocols should be referred as below: Patients who are Very Systemically Unwell Refer to ED High temperature, rapid pulse and Explain actions to patient and significant respiration rate, malaise, discharge ++ others ? dehydrated ? Mastoiditis Swelling / tenderness over mastoid bone associated with on going earache Requires ENT assessment

Refer to ENT SHO Explain actions to patient and significant others

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? Severe Otitis Externa: Requires ENT assessment

Refer to ENT SHO Explain actions to patient and significant others

Immunocompromised Patient If temperature >37 C Patient has an increased risk of complications:

Refer to General Practitioner or OOH: Patient requires Same Day appointment.

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

Go to referral pathway for Severe Otitis Externa

Go to treatment pathway for Furuncle (Boil) in ear canal

Go to treatment pathway for Acute Otitis Media

Go to treatment pathway for Perforated Tympanic Membrane

Go to treatment pathway for Viral Ear Infection

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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

Patients with penicillin sensitivity

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.

If perforation is a result of Otitis Media

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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EAR WAX PROTOCOL


EXCLUSIONS Patients with trauma to the ear Patients a history of previous ear surgery. Patients with a foreign body Patients who have a current or within the last 12 months a perforated tympanic membrane Any discharge or bleeding from the canal. Patients who are excluded form this protocol should be referred to their own General Practitioner ASSESSMENT Patient's are likely to have impacted ear wax if they present with: A self diagnosis with a past history of ear wax problems Hearing loss Subjective blocked ears or ear discomfort Earache Tinnitus or Vertigo Itchiness History of exposure to water - causes an expansion of the wax and this in turn blocks the ear canal Have ear wax visible in EAM MANAGEMENT (CKS, 2009) Physical examination is the main diagnostic tool. The patient should be positioned in a clear, bright light or lying on the examination couch. Examine both ears with auriscope Note whether wax is present and whether it appears to be impacted Exclude infection as cause of symptoms. If present go to appropriate protocol for Ear Ache section Advise the patient to apply ear drops at room temperature. Advice the patient to pour a few drops of olive oil into the affected ear and lie down on their side for a few minutes with the affected ear facing upwards. This will allow the drops to soak into the wax and soften it. Advise the patient to apply the drops 2 or 3 times for 3-5 days as above. Advise that the plug should eventually soften and fall out of the ear bit by bit. If no improvement after 3-5 days advice the patient to make an appointment with their Practice Nurse for ear irrigation

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.

Subacute wet/dry eczema

Chronic dry, itchy eczema

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INFECTED ATOPIC ECZEMA

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

ACUTE FORM ATOPIC ECZEMA

CHRONIC FORM ATOPIC ECZEMA

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,

If rash outside contact areas, creases of skin or localised to hands - refer to GP

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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ELECTRICAL INJURIES AND LIGHTNING STRIKES MANAGEMENT PROTOCOL


ASSESSMENT When the patient arrives at reception with an electrical injury or lightning strike 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 management and treatment. 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 having sustained an electrical injury or lightning strike should be assessed as below: Assess patient's immediate needs and take a brief history - these injuries vary enormously in their presentation, from virtually asymptomatic to life threatening cardiac arrhythmia. It is unusual for these to progress. The damage has been done. There is a risk of occult damage to muscles which has to be considered. Symptoms, no matter how unusual, should be taken seriously as the electrical energy can damage a variety of anatomical structures including, nerve, muscle, blood vessel, spinal cord, and cardiac muscle. The main symptom of an electrical injury is burns to the skin - especially at points of contact - hands, feet and head are common and mouths in children under 4 years. Remember also to look for an exit burn and to consider what structures the current may have passed through between the two sites. May have chest and/or abdominal pain Pain and/or tingling, numbness to limbs Period of unconsciousness Loss of vision, hearing (perforated ear drum in patients struck by lightening) or speech Other injuries if thrown clear of electrical source - fractures or dislocation from severe muscle contractures or falls MANAGEMENT OF LOW VOLTAGE (240 volts UK supply) ELECTRIC SHOCK (Scott, UK health information,2009) < 50 volts - No danger 240 volts creates small, deep entrance and exit wounds, often but not always close together Record observations- temperature, pulse, RR, BP, pulse oximetry Record 12 lead ECG. Urinalysis - any abnormality refer to ED If patient is pregnant they will need to be referred for ultrasound scan. Follow burn and tetanus management protocol. Electrical burns are always full thickness Follow fracture management protocol if applicable If the patient only has single entry wound, is asymptomatic and has a normal ECG (as diagnosed by ECG analysis and/or NP), they can safely be discharged with

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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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EMERGENCY HORMONAL CONTRACEPTION


EXCLUSIONS Children under 13 years of age Women over 60 years of age Children between 13 and 16 years of age that are not deemed Fraser competent under Fraser Guidelines by the Nurse Practitioner More than 72 hours have elapsed since the first episode of unprotected sex within the current menstrual cycle Women who have had Levonorgestrel EHC more than twice in any one cycle. Women excluded from Levonorgestrel PGD These patients must be referred to a medical practitioner or the Community Contraception & Sexual Health (CC&SH) Service. ASSESSMENT When assessing a patient you should: Access the patient in accordance with CC&SH Assessment sheet attached to Levonorgestrel EHC PGD. Children under 16 years of age: In the UK, people under the age of 16 years can consent for treatment if they have sufficient maturity and judgement to enable them to fully understand what is proposed. In England and Wales, it is lawful to provide contraceptive advice and treatment without parental consent, provided that the practitioner is satisfied that the following Fraser Guideline criteria (Teenage Pregnancy Unit 2001) are met: The young person understands the practitioners advice The young person cannot be persuaded to inform his or her parents or allow the practitioner to inform the parents that contraceptive advice has been sought The young person is likely to begin or to continue having intercourse with or without contraceptive treatment Unless he or she receives contraceptive advice or treatment, the young persons physical or mental health or both are likely to suffer The young persons best interest requires the practitioner to give contraceptive advice, treatment, or both without parental consent. Patients under 16 years must be assessed for Fraser competency. This assessment must be documented on the casualty card Note: child protection issues must be taken into account it is important to be satisfied that sex has been consensual and is not occurring in an incestuous or abusive relationship. If it is suspected that force has been used or that any sexual abuse has occurred, the NP must follow local Child Protection procedures. MANAGEMENT Patients who require emergency hormonal contraception should be managed as below: Take a full medical history.

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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

Transdermal hormonal contraceptive patch

incorrectly, torn/dislodged during intercourse, removed too early Patch off for longer than 48 hours

Patch off for less than 48 hours

Progestogen only pill (POP)

Progestogen only implants

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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Medroxyprogesterone acetate (DepoProvera)

Intra- uterine system (IUS) Intra -uterine Device (IUD)

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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FOREIGN BODIES IN EAR (REMOVAL OF)


Foreign bodies of the ear are common: children are seen mostly with toys, beads, folded paper, insect and seeds; adults attend mostly with cotton buds, insects and hearing aid batteries embedded - (CKS, 2009) EXCLUSIONS - THESE PATIENTS MUST BE REFERRED TO A DOCTOR Patients with uncharacteristic or excessive pain Patients with bleeding from the ear Patients with pus discharge from the ear Patients with a history of trauma - head injury related ASSESSMENT When assessing a patient you should: Assess for Hearing loss or sense of fullness Vertigo Pain Refer any patients demonstrating any of the above symptoms to a doctor MANAGEMENT Patients with foreign bodies in ears should be managed as below: Physical examination is the main diagnostic tool. The patient should be positioned in a clear, bright light or lying on the examination couch. Only attempt to remove visible foreign bodies from the ear 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. Suction using a fine suction catheter held in contact with the object is sometimes a useful method of removal 2. Use a blunt hook, crocodile or fine forceps. Place instrument behind the object and pull out or grasp object and remove. 3. Flush FB (foreign body) out of external canal using a syringe and saline. For insects lay the patient down. The insect should be killed prior to removal using Lidocaine than flush out. Irrigation is contraindicated for soft objects, organic matter and seeds which may swell when saturated. Do not push and avoid any interventions that may push the FB deeper into ear as this can cause damage to the Tympanic Membrane. 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) ALWAYS examine the ear after removal for evidence of any trauma caused during removal and for evidence of infection: If Otitis Media or Otitis Externa present then treat in accordance with the earache protocol. In the case of children only attempt removal if the child is co-operative, otherwise liaise with ENT department PHT. 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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FOREIGN BODIES IN THE NOSE (REMOVAL OF)


EXCLUSIONS Patients with uncharacteristic or excessive pain Patients with respiratory difficulty Patients with excessive bleeding from the nose THESE PATIENTS MUST BE REFERRED TO A DOCTOR ASSESSMENT When assessing a patient you should: Assess for pain, excessive bleeding or discharge Refer any patients demonstrating any of the above symptoms to a doctor

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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SIMPLE FRACTURE & INJURY MANAGEMENT


ASSESSMENT When assessing a patient you should: Assess and note the Time of injury and as exact a mechanism as possible. Seek specific clinical signs and symptoms of a fracture Deformity Swelling Localised bony tenderness Loss of skin colour Loss of Function Reduced movement Crepitus (should not be actively sought) Non-specific bruising and pain Record the site of any wound Record arterial pulses (the presence of an arterial pulse distal to an injury DOES NOT exclude vascular injury or compartment syndrome) Ask about and record any neurological Deficit. Record the dominant hand in upper limb injuries GENERAL MANAGEMENT ALL CHILDREN UNDER 2 YEARS ARE EXCLUDED FROM MIU X-RAY PROTOCOL 1. Patients with fractures should be generally managed according to the MIU Clinical Protocols. In certain in certain circumstances, such as, when the patient themselves has not presented at the time of the injury occurring, has been treated elsewhere, or has a pre-existing injury, the management described may not be appropriate. If in doubt the Nurse practitioner MUST contact ED for senior advice 37777 then select option 4 for the ED. The Nurse Practitioner should inform ED of all patients who are being transferred there, so that they can put them on the expected patients list on the computer system. 2. The patient must be assessed for pain, scored and appropriate analgesia administered as per PGD. Those patients whose pain cannot be managed by the appropriate MIU protocol or PGD will be transferred to hospital. 3. Remove any jewellery from the injured limb - rings (finger and toe), bracelets, watches, bangles and anklets etc. 4. Ensure examination of the whole limb including the joints above and below the area of injury. 5. Record whether there is an associated wound 6. Record whether there is displacement or angulation. 7. Check Tendon/Nerve function at and distal to injury site, any patients with injuries to Tendon/Nerves must be referred to hospital. 8. Treat soft tissue injuries dependent on severity of pain (record pain score) and/or swelling. Supportive bandage/sling may be applied, as appropriate. Always elevate limb when hand injuries 9. Consider Physiotherapy if appropriate. 10. All patients over 60 years presenting to the unit having sustained a fall must have a Falls Risk Assessment Tool (FRAT) completed and a Basic Information Care Assessment (BICA) (if applicable). 11. All patients who have a fracture must have a follow up appointment and be seen Fracture Clinic, Clinic 1 or MIU with Consultant review. Usually this should be within one week. Suspected scaphoid fractures should be seen in Clinic 1 (or MIU follow up) at 10-14 days. Fractures of the terminal phalanx of the fingers and toe fractures may be managed by the GP.

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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

Volar plate If lateral instability or large displaced fragment

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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Displaced, angulated or intraarticular fracture

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

PULLED ELBOW Clinical diagnosis based on history and examination

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

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

Discuss with senior in ED as above May need referral to Orthopaedics

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

If involves subtalar joint/depressed fracture

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

FRACTURE TALUS / SUBTALAR / MIDTARSAL

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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

Refer these patients to local Hospital to Orthopaedics

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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FRACTURE & SOFT TISSUE INJURIES OF THE NOSE


The Minor Injuries Nurse may assess patients with suspected fractured nose or soft tissue injury and complete initial treatments as defined within this protocol.
EXCLUSIONS Patients with associated Head Injury that are excluded under that protocol Patients with evidence of bony injury extending further onto the face (especially Zygoma #). Patients with obvious airway problems associated with nose injury. Patients with a septal haematoma THESE PATIENTS MUST BE REFERRED TO A MEDICAL PRACTITIONER ASSESSMENT When assessing a patient you should: Check and record baseline observations Assess and record length of time of any epistaxis at time of injury or discharge since Assess deformity of nasal skeleton and altered shape of the nose (this may be difficult initially due to soft tissue swelling and any previous # nose) Establish that the septum is midline Assess there is no septal haematoma (red swellings on the nasal septum) Assess the patient is able to breathe through each nostril Assess that there is no clinical evidence of bony injury to other areas of the face MANAGEMENT, TREATMENT AND ADVICE Patients with soft tissue injuries or fractures to the nose should be managed as below: N.B: Nose injuries in children under 10 years are unlikely to need manipulation, and it should be rare for them to need review. PATIENTS WITH OBVIOUS # NOSE REQUIRING IMMEDIATE MANAGEMENT - (CKS, 2009 and PHT ENT Consultant) Stop epistaxis as per protocol Deviation Epistaxis at time of injury/continuing Refer to Maxillofacial SHO for advice via switchboard Bilateral/Unilateral copy of clinical notes with patient Septal haematoma may be present Supply Analgesia according to pain score as per PGD Septum deviated Decrease airway to Advice patient not to blow or pick nose nostril

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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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FUNGAL INFECTIONS PROTOCOL


EXCLUSION Age < 2 months The immunocompromised patient with signs and symptoms of fungal infection Patients with a known allergy to Chrysanthemums Patients excluded from Topical antifungal treatment PGD ASSESSMENT When assessing a patient you should: Diagnosis is based on clinical history and examination and location of the infection MANAGEMENT, TREATMENT AND ADVICE Patients with symptoms specific fungal infections should be managed as below: ATHLETE FOOT - (CKS, 2007) Interdigital: White, macerated areas between the toes mainly 4th tinea pedis. Most common and 5th toes but may be more extensive. Uncommonly presents as dermatophyte dry cracked skin with erythema. Green or bluish discolouration infection implies secondary bacterial infection. Can spread to the plantar and dorsal surface of the foot and between other toes Moccasin Type: more diffuse, scaling pattern involving the entire sole and/or side of foot but usually the plantar arch and heel areas. White skin striae helpful in differential diagnosis. Often contains small red or brown papules/spots NAIL INFECTION - (CKS, 2007) tinea unguium or Patients often do not present until the nail becomes unsightly and onychomycosis painful Distribution is asymmetrical affecting 1or 2 nails on one hand or foot Affects the distal edge and side of the nail plate Nail plate is discoloured, Hyperkeratotic and friable Patients with proximal nail infections usually have a yeast infection caused by Candida Albicans. Patients also present with chronic paronychia with erythema and pustules In more significant cases, many nails may be affected and the entire nail plate is involved - thickened, discoloured (brown, white, yellow) and may be 'crumbling'

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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)

Altered responsiveness (e.g.


irritable, lethargic)

Skin colour unchanged Warm extremities Sunken eyes Dry mucous membranes
(except for mouth breathers in children)

Decreased level of consciousness Pale or mottled skin Cold extremities

Normal heart rate


(Face to Face Assessment)

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

Ref: Khanna, R.et al. BMJ 2009;338:b1350

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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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Weight loss Abdominal cramps Bloating or flatulence

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

SHINGELLOSIS (BACTERIAL DYSTENTERY)

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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MINOR HEAD INJURIES


EXCLUSIONS Infants < 1 year Adults > 65 years or over Patients on warfarin When assessing patients with a suspected head injury you should: Take:Full history - Mechanism of injury, Time of injury Any observed loss of consciousness Amnesia pre or post event Any visual disturbance Any vomiting or headache Size and position of any wound or Haematoma formation History of drug or alcohol intake History of epilepsy The assessment of conscious level should use the adult and paediatric versions of Glasgow Coma Score. The paediatric version should include 'grimace' alternative to record verbal score (for pre-verbal children) The Glasgow Coma Score should be recorded in clinical notes separate Eye (1-4) Verbal (V1-5) and Movement (M1-6) Scores (e.g.: E4, V4, M5) and a total GCS should be recorded based on a sum of 15 (13/15 in the example). The minimum possible score is 3, the maximum 9normal) is 15. The minimum head injury observations are: GCS, pupil size and reactivity, limb movements, respiration rate, heart rate, blood pressure and oxygen saturation rate. Criteria for referral to hospital emergency department should be followed for adults and children (using modified GCS) as per NICE Guideline 56 2007 GCS less than 15 on initial assessment Any loss of consciousness as a result of the injury Any focal neurological deficit since the injury (e.g. problems understanding, speaking, loss of balance, walking, weakness, visual changes, abnormal reflexes) Any suspicion of a skull fracture or penetrating head injury (e.g. clear fluid running from ears or nose, black eye with no associated damage around the eyes, bleeding from one or both ears, new deafness in one or both ears, bruising behind one or both ears, penetrating injury signs, visible trauma to the scalp or skull of concern to the nurse practitioner) Amnesia for events before or after the injury. The assessment of amnesia will not be possible in pre-verbal children or children under 5 years. Persistent headache Any vomiting episodes Any seizures Any previous cranial neurosurgical interventions A high energy head injury (e.g. pedestrian hit by car, passenger ejected from a car, fall from a height greater than 1 metre or more than 5 stairs, diving accident, high speed vehicle collision, involving motorised recreational vehicles, bicycle collision or any other high energy mechanism) History of bleeding or clotting disorder

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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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HEADACHE PROTOCOL EXCLUSIONS


Secondary headache disorders (attributed to another condition): Head and neck trauma e.g. whiplash or head injury Cranial or cervical vascular disorders e.g. stroke Non vascular intracranial disorders Substance use or withdrawal or medicine overuse Infections e.g. intracranial abscess, meningitis or encephalitis Disorders of homoeostasis e.g. fasting, sleep apnoea Disorders of structures of the head and neck e.g. sinusitis, acute glaucoma Psychiatric disorders Any other headache of unknown cause ASSESSMENT The majority of patients presenting with a headache have few physical signs. Diagnosis usually depends on headache history: General history - stressful job, history or migraines Family and personal history of migraines or frequent headaches Time of start of headache, frequency, any pattern and how long Pain: intensity, nature, site, spread and any associated symptoms Predisposing Factors: Stress, eaten certain foods, alcohol REFERRAL Patients who have a headache with symptoms below could have an underlying serious pathology - (CKS, 2009) Refer to ED Extremely severe headache (worst) Sudden onset headache - within seconds 9or woke Inform department of patients from sleep in absence of hangover provoking transfer history) Ambulance as required Severe photophobia Supply analgesia if not Fluctuating consciousness/drowsiness contraindicated as per pain score Seizure under PGD Abnormal neurological observations Neck stiffness High fever Profuse vomiting Rash

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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HEAD LICE PROTOCOL


EXCLUSIONS Children under 2 years and women who are pregnant or are breastfeeding for Insecticide treatment wet combing only Patients with asthma or severe eczema should not use alcohol based preparations ASSESSMENT When assessing a patient you should: The patient presents with itchy scalp. MANAGEMENT The head should be examined by using a comb to confirm or exclude infestation. TREATMENT AND ADVICE Choice of treatment depends on the preference of the individual and on treatment history. No treatment is 100% effective. WET COMBING METHOD -(CKS, 2007) Initial Wash hair to stop the lice from moving and then apply conditioner treatment to facilitate combing method and Use detection comb (available form community pharmacy) and all patients comb through hair to trap lice and nymphs. Wipe with a tissue can be after each stroke to prevent re-infesting the hair treated by Work systematically around the head. this method Rinse hair and repeat detection combing Repeat procedure on day 5, 9 and 13 and repeat as needed or until no lice on 3 consecutive sessions INSECTICIDE - (CKS, 2007) For patients who If wet combing fails Consult community pharmacist re OTC: have not yet used Phenothrin 0.5% liquid (Full Marks) or equivalent an insecticide Apply to dry hair and scalp, leave for 12 hours, rinse and Children under 2 repeat after one week years excluded. DIMETICONE TREATMENT(CKS, 2007) For head lice that are resistant Advise patient to see Community Pharmacist to other insecticides. Less re: OTC Dimeticone 4% lotion or equivalent effective against lice eggs Apply and leave on hair for 8 hours, rinse and repeat after one week Transmission of head lice can be controlled by treating whole family Dry Detection combing regularly. Children can attend school DISCHARGE Ensure patient has head lice information leaflet. 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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HERPES VIRUS PROTOCOL


EXCLUSION Age < 6 months Patients with cardiac disease, chronic skin disorders, glaucoma, bipolar disorder or renal impairment. The immunocompromised patient with signs and symptoms of herpes virus Pregnant women Patients with a recent history of shingles Patients with a rash near the eye, tip of nose or ear Children with an extensive rash have eczema, ophthalmic involvement, Ramsay Hunt Syndrome or are systemically unwell. Patients presenting with Herpes Varicella Zoster type rash more than 24 hours since the onset of that rash if already treated with aciclovir. Patients presenting with Herpes Zoster type rash more than 72 hours since the onset of that rash if already treated with aciclovir. ASSESSMENT When assessing a patient you should: Diagnosis is based on clinical history and examination. There are various types of the herpes virus but the most common types are:Type 1+2 - Herpes Cold sores, Gingivostomatitis Type 3 - Varicella Zoster Chicken Pox MANAGEMENT, TREATMENT AND ADVICE Patients with symptoms of a cold sore, gingivostomatitis, chicken pox or shingles should be managed and treated as below: COLD SORE TYPE HSV 1- Once Exposed to virus it remains dormant and can be activated by certain triggers. Small blister like lesions usually around the mouth (CKS, 2007) Primary infection symptoms General advice about the cause of the include swollen irritated gums with virus, possible reoccurrence and painful sores in and around the transmission mouth, sore throat, enlarged Treat symptomatically glands excessive salivating, fever, Paracetamol/Ibuprofen for pain dehydration, nausea and relief/pyrexia OTC or as per PGD headache. Treat lesions with OTC Choline Recurrent infections tend to be Salicylate Dental Gel e.g. Bonjela, less severe and shorter duration Blistex or Cymex with outbreaks of cold sores and Advise OTC Topical acyclovir if within 48 sometimes swollen glands for 7hours 10 days If not improving to contact own GP Avoid kissing and sharing cups

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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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INGESTED FOREIGN BODIES


EXCLUSIONS Patients with current choking, dyspnea or any respiratory distress Patients with dysphagia (difficulty in swallowing) Patients who have swallowed batteries (larger batteries may become stuck in the oesophagus causing perforation or later stenosis). Corrosive damage may occur from battery contents and electrical discharge. Cadmium and mercury may also be absorbed from leaking batteries, although there are been no reports of mercury poisoning. PATIENTS EXCLUDED MUST BE REFERRED TO ED Note: the patient that had a brief choking episode at time of swallowing but who is now asymptomatic and able to swallow without pain, may be treated by the Nurse Practitioner. ASSESSMENT When assessing a patient you should: Ascertain and record: What foreign body was swallowed and when Any respiratory distress Any choking Whether symptoms have ceased MANAGEMENT Patients with a foreign body should be managed as below: Provided that the foreign body reaches the stomach it is likely to pass through the remainder of the gastrointestinal tract without incident. Patients who are asymptomatic therefore need no active treatment, although X-ray may be indicated for radio-opaque foreign bodies if not excluded from xray protocol.

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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INGROWING TOENAIL PROTOCOL


EXCLUSIONS Patients with diabetes Patients with ischaemic lower limb ASSESSMENT When assessing a patient you should: Ascertain and record:Duration of problem Any discharge Any previous problems and treatment

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

Less common non-specific symptoms/signs NK NK NK NK NK NK NK More specific symptom/signs NK NK NK X X X X X X


Be aware that a rash may be less visible in darker skin tones - check soles of feet, hands and conjunctiva Includes confusion, delirium and drowsiness and impaired consciousness

Only relevant in children under 2 years

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

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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

Splinters wood, metal or other

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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NAPPY RASH PROTOCOL


EXCLUSIONS Any other rashes that are on the patients body that are outside the nappy area. ASSESSMENT When assessing a patient you should: Take a clinical history and examine the rash. Look for secondary infection MANAGEMENT Examine the infant/child carefully to ensure rash is confined to the area covered by the nappy. TREATMENT AND ADVICE Patients are deemed to be experiencing various degrees of nappy rash if they display the symptoms as listed and should be treated as below: MILD NAPPY RASH - - (CKS, 2007) Patient presents with First Line treatment is: redness to the skin area Advice frequency of changing nappies. Avoid covered by a nappy. tightly fitting waterproof pants. Infant/child may be mildly Washing affected area with soap and water only crying. Dry by patting the nappy area. Do not use talcum Slight genital thrush powder Apply barrier cream at the first sign of redness Allow the infant/child to spend time without a nappy on as may clear when exposed to the air. Barrier preparations can help: Consult community Pharmacy OTC re: Zinc and Castor oil, Metanium or Diprobase. Use cream after each nappy change and skin wash MODERATE/PERSISTENT NAPPY RASH - (CKS, 2007) Patient presents with: As per General Advice Deep redness to the skin If nappy rash not responded to barrier cream then area covered by a nappy topical corticosteroid cream anti-candidal creams Infant/child may be crying required and distressed Advise treat with OTC: Hydrocortisone cream Moderate genital thrush 1% and/or Clotrimazole 1% cream Apply clotrimazole before applying barrier cream Refer to General Practitioner within 72 hours. Refer to Health Visitor for advice PATIENT REFERRAL If other dermatological conditions are suspected or symptoms persist refer to the General Practitioner. Patients who require general advice re causative factors refer to Health Visitor 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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NECK 'WHIPLASH' INJURIES


EXCLUSIONS Patients whose mechanism of injury includes blunt trauma above the clavicle or high deceleration. 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 a history of neck surgery Patients with osteoporosis, premature menopause or use steroids Patients over 65 years ASSESSMENT When assessing a patient you should: The key to neck injuries is the detailed history of injury: Sitting in a car fitted with head restraints and wearing seatbelt - sustains rear end shunt (usually less than 20 mph)- safe injury and unlikely to have major injury (caution) A Front end shunt or incident on high speed road is more significant Try to assess impact forces - Damage to cars, double shunt into another car, windscreen bullseye, airbag deployment, estimated impact speed (beware this can be unreliable) What happened after the RTC - self extrication from vehicle? able to walk?, when did the pain start, stiffness, headache? Have they had any neurological symptoms (tingling, pins and needles, numbness, weakness) at any stage Assess alert trauma patients for risk of injury according to Canadian C-Spine rules (for alert (GCS =15) and stable trauma patients where cervical spine injury is a concern) 2003 see APPENDIX O MANAGEMENT Patients deemed to have a whiplash neck injury should be managed as below: ACUTE WHIPLASH - High risk factor which indicates x-ray- (Canadian C-Spine Rules, 2003. CKS, 2010) Age over 65 years Dangerous mechanism Fall from over 1 metre or 5 stairs Axial load to head e.g. rugby, diving, landing on head or wrestler High speed RTC (>30 mph)- rollover, ejection Motorised recreational vehicles Bicycle struck or collision Paresthesias in extremities If acute - C.Spine immobilisation Disabling neck pain - with midline c-spine tenderness Refer to ED by ambulance Acute Back pain identification band

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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.

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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.

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OPHTHALMIC INJURIES AND PROBLEMS


The Minor Injuries Nurse may assess and treat patients with Corneal, Subtarsal and loose Conjunctival foreign bodies and abrasions and provide emergency treatment for patients who have sustained chemical burns to the eyes.
All other ophthalmic injuries must be referred to the Royal Eye Infirmary (REI). The current REI ophthalmic clinical practices for guidance 1 -27 are available in paper and electronic form for staff with this ophthalmic protocol and have been agreed by PHT Royal Eye Infirmary OPHTHALMIC FOREIGN BODIES/ABRASIONS EXCLUSIONS If the patient has Loss of visual acuity, Pupil abnormality, If the foreign body is embedded, If there is a history of high velocity injury (e.g. hammering). If the patient has any severe pain, marked redness, photophobia, eye inflammation associated with a rash to the scalp or face, cloudiness, glaucoma, dry eye syndrome or any recent eye or laser surgery PATIENTS EXCLUDED MUST BE REFERRED TO THE ROYAL EYE INFIRMARY

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.

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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

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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

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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

0844 892 0111


Nurse Practitioners to follow advice as given by Toxbase staff and refer to A+ED or other health care professional as required following MIU procedures/practices If the patient has a Community Psychiatric Nurse (CPN) or equivalent, that person must be informed prior to discharge. In cases of children, consider Non-Accidental Injury and therefore also follow the PtPCH Child Protection Policies

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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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

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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.

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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.

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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

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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

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In elderly Palms, soles of feet and trunk

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

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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,

These patients should be referred to their GP for further assessment

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.

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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

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SORE THROAT PROTOCOL


EXCLUSIONS Patients with Epiglottitis, Patients with Quinsy, Patient is Immunocompromised: for these patients follow the referral advice within this protocol. If evidence of drooling, having breathing difficulties, stridor or unable to swallow DO NOT EXAMINE PATIENT, THIS IS AN ENT EMERGENCY GO TO REFERRAL PATHWAY FOR EPIGLOTTITIS ASSESSMENT When assessing a patient, you should: Take a full history and examine the throat and neck Patients are deemed to be experiencing a sore throat if they display some or all of the symptoms listed below: Painful swallowing, Pyrexia/fever, Associated earache, Coryza, Rash, Malaise, Hoarseness, Stiff Neck MANAGEMENT - (CKS, 2009) Patients with sore throat symptoms should be managed and treated as listed below: Palpate cervical and submandibular lymph glands for enlargement or tenderness (lymphadenopathy) Examine for evidence of a rash, noting its colour, character, distribution and blanching Examine oropharynx. Measure and record temperature on the patients records. If temperature > 37o C and immunocompromised Go to referral pathway for Immunocompromised Patient.

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

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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

Go to treatment pathway for Acute Tonsillitis

Go to treatment pathway for Laryngitis

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

Refer to General Practitioner/OOH Same Day

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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

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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

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REMOVAL OF LOST TAMPONS


The Minor Injuries Nurse may remove lost tampons that are caused by either: Faulty tampon, lost tampon strings, inserting a second tampon, Sexual intercourse during menstruation with tampon in place

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

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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.

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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

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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

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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.

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the emergency department.

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.

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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.

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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

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WART AND VERRUCA PROTOCOL


EXCLUSIONS Only if treatment is required pregnant women, women who are breastfeeding and those with poor circulation should be referred to a doctor. ASSESSMENT When assessing a patient, you should: Patients usually have no symptoms with cutaneous warts but plantar and periungual warts can be painful. Type Site Common wart Typically occur on the hands (palmar warts), elbows, and knees, but can occur anywhere Plane wart Typically occur on (flat warts) the hands, face, and legs, usually in young children (rare in adults) Plantar warts (verrucas) Occur on the soles of feet, as well as heels and toes. Can be overlying the metatarsal heads, but also consider calluses in pressure-point areas. Hands or feet Appearance Firm, rough, keratotic papules and nodules Number Single or multiple, but usually less than 20 One to a hundred; may coalesce

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

Exposed skin areas face, arms and hands

(Reference: CKS, 2007)

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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

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WOUND MANAGEMENT PROTOCOL


EXCLUSIONS Refer to a doctor, wounds that: May have damage to underlying structures e.g. tendon or nerve damage (particularly hand/wrist wounds) Require debridement or decompression of devitalised tissue Are deep facial wounds, especially those involving eye, lip and ear margins. Contain foreign bodies that are not easily removed Deep wounds that are present over joints Show signs of ascending lymphangitis/systemic infection and patient unwell GENERAL ASSESSMENT When generally assessing a patient, you should: Listen to the patient and take time to examine the wound and deeper structures aswell as: History of injury, mechanism of injury, possibility of a foreign body, possibility of high pressure injection, risk of infection or contamination, past medical history, tetanus status, allergies and current medication. Whether the patient is right or left handed (if presenting with upper limb injuries) Occupation of patient Examine the wound, burn or scald: site, shape, length, depth and any gapping. Note any underlying structure involvement (tendon or nerve damage), foreign bodies, blistering or dirt/debris. Anatomical function, Neurological function and Circulatory function distal to the injury All wounds or burns should be cleaned, irrigated, dried and inspected (may need to use magnifying goggles). Determine if there is any underlying bony tenderness. MANAGEMENT OF WOUNDS ABRASIONS Patient presents with varying sizes and depths of scrapes to the skin Clean the abrasions thoroughly with saline (may need local anaesthetic if not contraindicated) Remove pieces of grit/debris Most facial abrasions can be left open, apply or advice liquid paraffin A dab of Providine Iodine as per PGD can be used as an antiseptic and a drying agent Apply non adhesive dressing If anti-tetanus therapy required, treat in accordance with Tetanus protocol Review MIU dressing clinic in 24 hours

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.

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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

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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

DGH - Clingfilm only Refer to ED

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

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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

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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

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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

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Intra - oral/tongue/gum

Facial Torn Frenulum Lips

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

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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

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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

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Combined Tetanus Vaccines Protocol


(Pediacel /Repevax/ Revaxis and Human Tetanus Immunoglobulin 250IU Injection) CLINICAL CONDITION Active immunisation against tetanus in patients who have sustained a tetanus-prone wound Management of *tetanus-prone wounds Tetanus Vaccines Tetanus Immunoglobulin

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.

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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)

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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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NURSE REQUESTED X-RAYS


The nurse practitioner may request x-rays, when clinical assessment indicates either a suspected fracture or a suspected embedded foreign body i.e. metal or glass
EXCLUSIONS 1. Rose thorns, wooden splinters or other organic FB, these do not show up on x-ray. 2. Patients who may have sustained serious/multiple injuries that are best managed in ED should not have their transfer to ED delayed due to nurse requested x-rays. 3. Children under 2 year of age. INCLUSIONS. Nurse practitioners requesting x-rays should have undertaken training which satisfies IRMER requirements Nurses may only request x-rays for: 1. The upper limb. 2. The lower limb below the thigh 3. Foreign Bodies MANAGEMENT Patients that require an xray should be managed as below: All nurse practitioners requesting x-rays should do so within their agreed scope of practice, competency and within this protocol NEVER request an X-ray until a comprehensive history and full clinical examination has been completed. To minimise radiation consider whether an x-ray will alter your management. If wound sustained on breaking glass and X-ray unavailable, discuss with ED with view to transfer. The request form MUST be filled in completely else the radiographer may not take the appropriate views. Include: 1. History and mechanism of injury 2. Site of Injury and which side 3. Previous injury and surgery 4. Suspected Bony Diagnosis 5. If a fracture is suspected which require special views i.e. scaphoid state this on the request form. 6. Ensure the request form has the MIU address and telephone number in case urgent action is required for unexpected findings. Nurse requested x-rays may be performed on the less seriously injured, which nevertheless requires review at the local ED department, providing it does not delay the patients transfer, such as: high-pressure injection injuries. Injuries suspected to have penetrated a joint. All x-rays requested are to be recorded in the current xray book and the initial interpretation documented. The MIU x-ray lead nurse will ensure all x-rays are reported on and the report documented in the x-ray book. Any urgent or unexpected findings will be acted upon as per appropriate protocol. The patient GP will also receive notification of the initial x-ray result, planned follow and

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any unexpected findings.

Evaluation following x-ray and radiological diagnosis.


1. The radiographer using the red dot system will advise on initial x-ray interpretation. 2. The advised initial interpretation result to be recorded in the current x-ray book 3. If an obvious bony injury is immediately noted, the MIU staff in accordance with the appropriate protocol will instigate the approved treatment. 4. All x-ray reports will be reconciled in the x-ray book and any missed fractures or concerns will be acted upon on the day of receiving the x-ray report by the nurse practitioners and actions will be documented on the patient's casualty card. 5. Patients attending from out of area that require fracture follow up will need request form to be completed for images to be copied to CD (Appendix G) or found on shared drive. Procedure: a) Monday - Friday 9am - 5pm the Nurse Practitioners to email Radiology IT with completed electronic form and print a copy for clinical records. Outside these hours contact ED X-ray department and the bleep holder will organise; also email IT radiology b) Radiology IT will make a copy of the X-ray onto CD but this will take 24 hours and they will send to MIU. c) Patient/carer to collect CD from MIU and If not collected, to be returned to IT imaging for destruction

No patient shall be discharged from the MIU until either:


1. Appropriate treatment has been instigated for bony injuries. 2. Appropriate investigation, diagnosis and treatment have been completed for conditions that do not include a bony injury. 3. All documentation is completed in accordance with MIU documentation protocol.

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6. REFERENCES AND FURTHER READING LIST


Alcock J, Delieu J (2007) Planning for pandemic influenza. Nursing Standard, 22, 3, 3539. Anderson I (2006) Debridement methods in wound care. Nursing Standard. 20, 24, 6572. American Society for Surgery of The Hand (1990). THE HAND. Churchill Livingstone. Assessment made Incredibly Easy. Second Edition (2002). Backhouse K M, Hutchings R T (1998). Sprinhouse Pennsylvania. Mosby-Wolfe.

Clinical Surface Anatomy.

Bache JB, Arraitt CR, Tobiss JR (1990). A Colour Atlas of Nursing Procedures in Accident & Emergencies. Wolfe Medical Publications Ltd. Baird A (2005) Independent and supplementary prescribing and PGDs. Nursing Standard. 19, 51, 51-56. Bakalis NA, Watson R (2005) Nurses decision-making in clinical practice. Nursing Standard. 19, 23, 33-39. Bedford H (2003). Measles: the disease and its prevention. Nursing Standard. 17, 24, 46-52. Benbow, M (2004) Wound Management Materials. Practice Nurse. Vol 28,Issue 1; pg19. Bethell E (2005) Wound care for patients with darkly pigmented skin. Nursing Standard. 20, 4, 41-49. Booker R (2007) Correct use of nebulisers. Nursing Standard. 22, 8, 39-41. Blackey P (1992). The muscle book. Bibliotek books.

Booker R (2007) Peak expiratory flow measurement. Nursing Standard. 21, 39, 42-43. Boyne L (2001). Meningococcal infection. Nursing Standard. 16, 7, 47-53.

Briggs J K. (2002). Telephone triage Protocols for Nurses. Second Edition. Lippincott Williams & Wilkins. British Association for Accident and Emergency medicine (2004). Guideline for Management of Pain in Children. http://www.beam.org.uk/home.html British National Formulary (2008). BMJ BOOKS & Pharmaceutical Press. British Guideline on the Management of Asthma. A national clinical guideline (2009). http://www.bnt-thoracic.org.uk.

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Brown A, Butcher M, (2005) A guide to emollient therapy. Nursing Standard. 19, 24, 6875. Brown P W (2007) Evaluation focuses on tendons, nerves and vessels pointers for managing common hand injuries. The journal of musculaoskeletal hand injuries. Vol 24, Is 8; pg354 Buchanan P, Courtneay M (2007) Topical treatments for managing patients with eczema. Nursing Standard. 21, 41, 45-50. Burnard P, Chapman CP (1999). Professional & Ethical Issues in Nursing second edition Bailliere Tindall. Burr S Penzer R (2005) Promoting skin health. Nursing Standard. 19, 36, 57-65. Burton F (2004) Benchmarking and wound care in A&E. Nursing Standard. 18,45, 6772. Cable S et al (2003). Informed consent. Nursing Standard. 18, 12, 47-53. Cameron J (2004). Exudate and care of the peri-wound skin. Nursing Standard. 19, 7, 62-68. Campbell S (2007) The need for a global response to antimicrobial resistance. Nursing Standard. 21, 44, 35-40. Caress AL (2003). Giving information to patients. Nursing Standard. 17, 43, 47-54.

Carroll L (2004). Clinical skills for nurses in medical assessment units. Nursing Standard. 18, 42, 33-40. Clinical knowledge Summaries (2007) Allergies www.cks.library.nhs.uk Clinical knowledge Summaries (2010) Asthma www.cks.library.nhs.uk Clinical knowledge Summaries (2007) Bites- Human and animal.www.cks.library.nhs.uk Clinical knowledge Summaries (2007) Boils, carbuncles, folliculitis. www.cks.library.nhs.uk Clinical knowledge Summaries (2007) Burns and scalds www.cks.library.nhs.uk Clinical knowledge Summaries (2007) Cardiovascular www.cks.library.nhs.uk Clinical knowledge Summaries (2009) Child Healthwww.cks.library.nhs.uk

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Clinical knowledge Summaries (2007) Conjunctivitis. www.cks.library.nhs.uk Clinical knowledge Summaries (2009) Ears, Nose and Throat www.cks.library.nhs.uk Clinical knowledge Summaries (2007) Earwax www.cks.library.nhs.uk Clinical knowledge Summaries (2010) Gastroenteritis management www.cks.library.nhs.uk Clinical knowledge Summaries (2009) Headache www.cks.library.nhs.uk Clinical knowledge Summaries (2007) Infections and infestations www.cks.library.nhs.uk Clinical knowledge Summaries (2007) Lacerations www.cks.library.nhs.uk Clinical knowledge Summaries (2007) Oral health www.cks.library.nhs.uk Clinical knowledge Summaries (2010) Neck pain - whiplash injury www.cks.library.nhs.uk Clinical knowledge Summaries (2009) Neck pain - non specific www.cks.library.nhs.uk Clinical knowledge Summaries (2009) Neck pain - torticollis www.cks.library.nhs.uk Clinical knowledge Summaries (2007) Respiratory www.cks.library.nhs.uk Clinical knowledge Summaries (2007) Skin and nails www.cks.library.nhs.uk Clinical knowledge Summaries (2007) Sexual Health www.cks.library.nhs.uk Clinical knowledge Summaries (2007) Urology www.cks.library.nhs.uk Clinical knowledge Summaries (2007) Womens health www.cks.library.nhs.uk Cole E (2003). Wound management in the A&E department. Nursing Standard. 17, 46, 45-52.

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Cole E (2004). Assessment and management of the trauma patient. Nursing Standard. 18, 41, 45-51. Cole E (2007) Wound closure using adhesive strips. Nursing Standard. 22,9, 48-49. Cook SH et al (2004). Self-harm and suicide: care, interventions and policy. Nursing Standard. 18, 43, 43-52. Cooke M, Jones E, Kelly C 1998 Minor Injuries Unit Handbook. Butterworth Heinemann Compendium of Data Sheets & Summaries of Product Characteristics (1998-99). ABPI. Cork A (2007) Theory and practice of manual blood pressure measurement. Nursing Standard. 22,14-16, 47-50. Crown J Dr. (1998). Crown Report, Review of Prescribing, Supply and Administration of Medicines. March edition. Daley B J, Aycinena J F, Mallak AF. (2008) Electrical Injuries. eMedicine medscope. article/433682. Dandy DJ (1993). Essential orthopaedics and trauma second edition. Churchill Livingstone. Davies A (2007) Nursing care and management of patients with pruritus. Nursing Standard. 21, 41, 51-57. Dawes E et al (2007) Monitoring and recording patients neurological observations. Nursing Standard. 22, 10, 40-45. Dean R (2005) Emergency first aid for nurses. Nursing Standard. 20, 6, 57-65. Department of Health (2000). Ionising Radiation (Medical Exposure) Regulations http://www.dh.gov.uk Department of Health (2002). Update on immunisation issues: http://www.dh.gov.uk/cmo/index.htm Department of Health (2003). What To Do If Youre Worried A Child Is Being Abused. DoH Publications London. Departmental Guidelines (2004). Derriford Hospital Accident and Emergency Department. Department of Health (2004). Change in names of certain medicinal substances. http://www.dh.gov.uk/cmo.htm Department of Health (2006) Immunisation against infectious diseases 2006 The Green Book. http://www.dh.gov.uk

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Department of Health (2006) Medicines Matters. A guide to mechanisms for the prescribing, supply and administration of medicines. http://www.dh.gov.uk Department of Health (2006). Ionising Radiation (Medical Exposure) (Amendment) Regulations 2006: A consultation. http://www.dh.gov.uk Devlin-Rooney K, James W (2005) Management and prevention of abnormal scars. Nursing Standard. 19, 28, 45-54. Dimond D (1990). Legal Aspects of Nursing. Prentice Hall. Dimuzio J, Deschler D G, (2002) Emergency department management of forgein bodies of the external canal in children. National Library of Medicine. July; 2394): 47 Dowsett C (2004) The use of silver-based dressings in wound care. Nursing Standard. 19, 7, 56-60. DTB (2004). Managing bites from humans and other mammals. DTB. 42, 9, 67-71. Dunn L (2005) Pneumonia: classification, diagnosis and nursing management. Nursing Standard. 19, 042, 50-54. Du Plat-Jones J (2006) Domestic violence: the role of health professionals. Nursing Standard. 21. 14-16. English John (2009) Chronic hand eczema - information for nurses. Independent Nurse Epstein, Perkin, de Bono, Cookson (1997). Mosby. Clinical Examination second edition

Ewles & Simnett (1996). Promoting Health A PRACTICAL GUIDE Bailliere Tindall Exeter Walk-in-Centre (2004). Protocols and PGDs for Nurse Practitioners. Farley A, Hendry C, Napier P (2005) Paracetamol poisoning: physiological aspects and management strategies. Nursing Standard. 19, 38, 58-64. Field D (1997). Anatomy, palpation & surface markings. Butterworth Heinemann. Finney A, Rushton C (2007) Recognition and management of patients with anaphylaxis. Nursing Standard. 21, 37, 50-57. Fowler A (1998) Nursing management of minor burn injuries. Nursing Standard. Vol 12, Issue 49; pg47 Frost KJ (2007) An overview of antibiotic therapy. Nursing Standard. 22, 9, 51-57. Fullbrook S (2007) Infection control legislation for medical devices. Nursing Standard. 22, 13, 51-54. Gandham SG, Menon D (2003). Prospective randomised trial comparing traditional

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suture technique with the dynamic sliding loop suture technique in the closure of skin lacerations. Journal Accident Emergency Medicine. 20:33-36. Gardiner A (2004). Rectal irrigation for relief of functional bowel disorders. Nursing Standard. 19. 9, 39-42. Gardner G et al (2004). Nurse practitioner education: a research-based curriculum structure. Journal of Advanced Nursing. 47, 2, 143-152. Gould D (2004). Bacterial infections: antibiotics and decontamination. Nursing Standard. 18,40, 38-42. Griffith R (2003) Immunisation and the law: compulsion or parental choice. Nursing Standard. 18, 10, 39-41. Group protocols for MIU nurses (1999). Cornwall Healthcare Trust. Guly HR (1994). History taking, examination & record keeping in emergency medicine. Oxford University Press. Guly HR (2002) Injuries initially misdiagnosed as a sprained wrist (Beware the sprained wrist) Emergency Medicine Journal. 19:41-42. Hall J, Horsley M (2007) Diagnosis and management of patients with Clostridium difficile associated diarrhoea. Nursing Standard. 21, 46, 49-56. Hand H, Banks A (2004). The contents of the resuscitation trolley. Nursing Standard. 18, 44. 43-52. Hart S (2006) Ionising radiation: promoting safety for patients, visitors and staff. Nursing Standard. 20, 47, 47-57. Hart S (20070 Using an aseptic technique to reduce the risk of infection. Nursing Standard. 21, 47, 43-48. Health Protection Agency: Guidelines for the management of human bite injuries. www.hpa-nw.org.uk Health Protection Agency (2006) Diagnosis of UTI. Quick reference guide for primary care. Guidelines for the management of human bite injuries. www.hpa-nw.org.uk Health Service Circular (2000). Patient Group Directions HSC 2000/026 NHS Executive. Heenan A (2007) Algionates: an effective primary dressing for exuding wounds. Nursing Standard. 22, 7, 53-60. Hendry C, Farley AH (2001) Understanding allergies and their treatment. Nursing

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Standard. 15, 35, 47-52. Hewitt-Taylor J (2003). Developing and using clinical guidelines. Nursing Standard. 18, 5, 41-44. Home Office Circular (2003). Misuse of Drugs (Amendment) (No 3) Regulations 2003 (SI No: 2429/2003). http://www.homeoffice.gov.uk/docs2/hoc4903htm Hopcroft K & Forte V (1999). Symptom sorter. Radcliffe Medical Press. Hopkinson K, Powell P (2003). Management of allergic rhinitis. Nursing Standard. 17, 40, 47-52. Hudspith J, Rayatt S (2004). First aid and treatment of minor burns. BMJ 328, 7454, 1487-1489. Hunter J (2008) Intramuscular injection techniques. Nursing Standard. Vol 22. no 21. 41-44 Hunter J (2008) Subcutaneous Intramuscular injection techniques. Nursing Standard. Vol 22. no 24. 35-40 Hutchinson C (2005) Addressing issues related to adult patients who lack the capacity to give consent. Nursing Standard. 19, 23, 47-53. Ingrowing toenail treatments (1999) Bandolier. 69 (11) 1-2 Jamison J (1999). Jenner E (1996). Differential diagnosis for primary care. Churchill Livingstone. Immunisation against Infectious Disease HMSO.

Joanna Briggs Institute (2008) Solutions, techniques and pressure in wound cleaning. Nursing Standard. Vol 22, no 27, 35-40 Johnson G, Hill-Smith I, Ellis C (2000). The Minor Illness manual Second Edition. Radcliffe Medical Press. Jibuike OO et al (2003). Management of soft tissue knee injuries in an accident and emergency department: the effect of the introduction of a physiotherapy practitioner. Journal Accident Emergency Medicine. 20:37-39. Johnstone CC, Farley A, Hendry C (2005) The physiological basics of wound healing. Nursing Standard. 19, 43, 59-65. Judge NL (2007) Neurovascular assessment. Nursing Standard. 21.45. 39-45 Kaufman G (2010) Developing patient group directions for medicines management. Nursing Standard. 24. 48, 50-56. Kaufman G (2008) Non-medical prescribing using the British national formulary.

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Nursing Standard. 22, 20,51-56 Khanna R et al (2009) Diarrhoea and vomiting caused by gastroenteritis in children under 5 years: summary of NICE guidance. BMJ; 338: 1350 Kilroy DA et al (2003). Emergency department investigation of deep vein thrombosis. Journal Accident Emergency Medicine. 20:29-32. Kindleysides D (2007) First aid: basic procedures for nurses. Nursing Standard. 21, 18, 48-57. Kraszewski S (2007) Procedure for pregnancy testing. Nursing Standard. 22, 12, 45-48. Langford R W, Thompson J D (2000). Handbook of Diseases. Second edition. Mosby. Larson D (2002). Assessment and management of foot and ankle fractures. Nursing Standard. 17, 6, 37-46. Lawton S (2004) Effective use of emollients in infants and young people. Nursing Standard. 19, 7, 44-50. Leaman AM (2003). See and Treat: a management driven method of targets or a tool for better patient care? One size does not fit all. Journal Accident Emergency Medicine. 20:118. Leyshon J (2007) Correct technique for using aerosol inhaler devices. Nursing Standard. 21, 52, 38-40. Lloyd H, Craig S (2007) A guide to taking a patients history. Nursing Standard. 22, 13, 42-48. Lloyd Jones M (2004). Minimising pain at dressing changes. Nursing Standard. 18, 24, 65-70. Lumley JSP (1996). Surface anatomy second edition. Churchill Livingstone.

Mackechnie C, Simpson R (2006) Traceable calibration for blood pressure and temperature monitoring. Nursing Standard. 21, 11, 42-47. Malcolm A (2006) Medical imaging techniques: implications for nursing care. Nursing Standard. 20, 41, 46-56. Mallett J & Bailey C (2000). Manual of Clinical Nursing Procedures Fifth edition. Blackwell Science. Mantooth R (2009) Foreign bodies ear. Electronic medical http://emedicine.medscope. Mason I (2007) Continence care for patients with inflammatory bowel disease. Nursing Standard. 22, 8, 43-46.

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Martin j (2005) Clinical negligence and patient compensation. Nursing Standard. 19, 25, 35-39. Matiti M et al (2007) Promoting patient dignity in healthcare settings. Nursing Standard. Vol 21. no 45. 46-52 McGeehan R (2007) Best practice in record-keeping. Nursing Standard. 21,17,51-55. McLafferty, E, Farley A (2008) Assessing pain in patients. Nursing Standard. Vol 22, no 25, 42-46 McGarry G W, Moulton C (1993) The first aid management of epistaxis by accident and emergency department staff. Archives of emergency medicine, 10, 298-3000. McGloin S (2008) Administration of oxygen therapy. Nursing Standard. 22,21,46-48 McRae R (1994). Practical Fracture Treatment. Churchill Livingstone 3rd Edition. McRae R & Kinninmonth AWG (1997). Orthopaedic and trauma. Churchill Livingstone. Meningitis Research Foundation (2002). Early Recognition of Meningitis and Septicaemia. (Vital signs for front line nurses). www.meningitis.org MeRec Bulletin (2006) acute uncomplicated urinary tract infection in women: bulletin volume 17, number 3. Montgomery J (1997). Health Care Law. Oxford Press. Moore K L (1985). Clinically oriented Anatomy Third edition. Williams & Wilkins. Moore T (2007) Respiratory assessment in adults. Nursing Standard. 21, 49, 48-56. Munroe J & Edwards CRW (1995). Macleods clinical examination. Churchill livingstone. Naidoo J, Wills J (1997). Health promotion Foundations for Practice Bailliere Tindall. Nathan A (2005) Non-prescription medicines: prescribing legislation. Nursing Standard. 19, 52, 41-45. National Prescribing Centre (2004). Patient Group Directions, A practical guide and framework of competencies for all professionals using patient group directions. www.npc.co.uk. Neal M J (1997). Medical Pharmacology at a Glance. Blackwell Science. NICE clinical guideline 45. (2007) Atopic eczema in children. www.nice.org.uk

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NICE clinical guideline . (2010) Bacterial meningitis and meningococcal septicaemia in children . www.nice.org.uk NICE clinical guideline .73 (2010) Chest Pain of recent onset. www.nice.org.uk NICE Guideline 84 Diarrhoea and vomiting in Children (2009) www.nice.org.uk NICE clinical guideline 47. (2007) Feverish illness in children. www.nice.org.uk NICE clinical guideline 56. (2007) Head injury. www.nice.org.uk NICE clinical guideline 16. (2004) Self-harm. www.nice.org.uk NICE clinical guideline 54. (2010) UTI in children. www.nice.org.uk NICE clinical guideline 25. (2007) Violence: The short-term management of disturbed/violent behaviour in psychiatric in-patient settings and emergency departments. www.nice.org.uk Nicholson DA & Driscoll PA (1996). ABC of emergency radiology second edition. BMJ. Nurse Prescribers: Respiratory illness 1 Sore throat. (2002) Primary Health Care. 12, 8, 33-34. Nurse Prescribers: Respiratory illness 11 Cough. (2002) Primary Health Care. 12, 9, 35-36. Nurse Prescribers: Respiratory illness 111 Colds and flu. (2002) Primary Health Care. 12, 10, 33-34. Nursing & Midwifery Council (2004). The NMC Code of Professional Conduct: standards for conduct, performance and ethics. London. Nursing & Midwifery Council (2005). Complaints about professional conduct. London. Nursing & Midwifery Council (2008). Guidelines for the administration of medicines. London. Nursing & Midwifery Council (2005). Guidelines for records and record keeping. London. Nursing & Midwifery Council (2002). Practitioner-client relationships and the prevention of abuse. London. Nursing & Midwifery Council (2004). Professional advice from the NMC. London.

Patient UK (2010) Whiplash and cervical spine injury - leaflet. http://www.patient.co.uk Pettersa L, Renstram P (2005) Sports Injuries: their prevention and treatment 3rd Ed. Taylor and Francis. London

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Poisonous Plants & fungi (1988). HMSO London. Plymouth Area Joint Formulary (2007) www.pajf.plymouth.nhs.uk Plymouth Hospitals NHS Trust (2007) Pathology Handbook. Plymouth Primary Care Trust (2010) Emergency Contraception Policy Plymouth Primary Care Trust (2008). Protocol for the provision of Basic Life Support. Plymouth Primary Care Trust (2009) Screening for Chlamydia and other genital infections Policy Plymouth Primary Care Trust (2009) Management of severe anayphylaxis. Resuscitation training officer. Poole C (2002). Diagnosis and management of urinary tract infection in children. Nursing Standard. 16, 38, 47-52. Prodigy (2004) Guidance http://www.prodigy.nhs.uk. Prodigy (2004) Guidance http://www.prodigy.nhs.uk. Bites human and animal. Contraception - emergency. http://www.prodigy.nhs.uk.

Prodigy (2004) Guidance Insect bites and stings. Prodigy (2007) Guidance

Lacerations. http://www.prodigy.nhs.uk

Prodigy (2004) Guidance Sprains. http://www.prodigy.nhs.uk. Prodigy (2004) Guidance Urinary tract infection (lower) women. http://www.prodigy.nhs.uk. Project Team of The Resuscitation Council (UK) (2001). Update on the emergency medical treatment of anaphylactic reactions for first medical responders and for community nurses. Emergency Medical Journal 18:393-395. Purcell D (2003). Minor Injuries A Clinical Guide for Nurses. Churchill Livingstone. Raby N, Berman L, Delacey G (1997). Accident & Emergency Radiology-A Survival Guide. Read M (2004). 2nd Ed A Practical Guide to Sports Injuries: A guide to self diagnosis.. Butterworth Heinemann. Rees M, Butler C (2001). Coughs and colds: nurse management of upper respiratory tract infection. Nursing Standard. 15, 39, 33-35. Resuscitation Council (UK) (2008) Emergency treatment of anaphylactic reactions:

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Guidelines for healthcare providers. . http://www.resus.org.uk/pages/anaphylaxis.htm Resuscitation Council (UK) (2005). Guidance for safer handling during resuscitation in hospitals. http://www.resus.org.uk/pages/reaction.htm Resuscitation Council (UK) (2005). Basic Life Support guidelines. http://www.resus.org.uk/pages/reaction.htm Resuscitation Council (UK) (2005). Adult Advanced Life Support guidelines. http://www.resus.org.uk/pages/reaction.htm Resuscitation Council (UK) (2005). The emergency Medical treatment of Anaphylactic Reactions for Medical Responders and Community Nurses. http://www.resus.org.uk/pages/reaction.htm Resuscitation Council (UK) (2005). Paediatric Advanced Life Support guidelines. http://www.resus.org.uk/pages/reaction.htm Resuscitation Council (UK) (2008). Whats New in May 2008. http://www.resus.org.uk Reynolds T (2004). Ear, nose and throat problems in Accident and Emergency. Nursing Standard. 18, 26, 47-53. Reynolds T, Cole E (2006) Techniques for acute wound closure. Nursing Standard. 20, 21, 55 -64. RCN (1998). Nursing Children in the Accident & Emergency Department RCN publishing company. Richardson M (2003). Wound closure. Emergency Nurse. 11, 3, 25-32. Richardson M (2004) The benefits of larval therapy in wound care. Nursing Standard. 19, 7, 70-76. Ronda L, Jones L (2005) Treating severe psoriasis: an update. Nursing Standard. 20, 4, 57-65. Royal College of Paediatrics and Child Health (2002). Childrens Attendance at a Minor Injury / Illness Service (MIS). http://www.rcpch.ac.uk Royal Eye Infirmary (undated). Clinical practice Guidelines. Plymouth Hospitals Trust. Royal Pharmaceutical Society of Great Britain (2008) Legal and ethical advisory service. Patient group directions: a resource pack for pharmacists. London Rycroft R, Robertson S (2005). A Colour Handbook of dermatology. Manson Publishing. Scales K (2008) A practical guide to venepuncture and blood sampling. Nursing

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Standard. Vol 22. no 29. 29-36 Scanion E (2005) Wound infection and colonisation. Nursing Standard. 19, 24, 57-67. Schilling JA, McCann, RN,(2002) Rapid Differential Diagnosis (2002). Springhouse, Philadelphia. Scott O, (2009) Electrical injuries and lightening Strikes. Patient UK Health Information Resources. http://www.patient.co.uk Shoqirate N (2006) Nursing students understanding of the Glasgow Coma Scale. Nursing Standard. 20, 30, 41-47. SkillMasters 3-Minute Assessment. (2003). Lippincott Williams & Wilkins., Philadelphia. Smith S (2006) Cross-cultural information leaflets. Nursing Standard. 21, 4, 39-41. Smoker A (1999) Fungal infections. Primary Health Care 9,1,31-38. Steggall MJ (2007) Urine samples and urinalysis. Nursing Standard. 22, 14-16, 42-45. Stiell I G et al (2003) The Canadian C Spine Rule. New England Journal of Medicine. 357: 1391-96 Swaby- larson D et al (2009) Xray interpretation by emergency nurse practitioners. Emergency Nurse. Vol 17, no 6 Thomas T (2007) Providing pain relief for patients in the emergency department. Nursing Standard. 22, 9, 41-45. Tompson G L (2009) Atrauma: a descriptive evaluation by historical review and by one specific case study. Tough J (2004). Assessment and treatment of chest pain. Nursing Standard. 18, 37, 45-53. Tough J (2005) Thrombolytic therapy in acute myocardial infarction. Nursing Standard. 19, 37, 55-64. Voegeli D (2007) The role of emollients in the care of patients with dry skin. Nursing Standard. 22, 7, 62-68. Walch E (2005) Headache. Nursing Standard. 19, 24, 45-52. Wallymahmed M (2007) Capillary blood glucose monitoring. Nursing Standard. 21, 38, 35-38. Wallymahmed M (2008) Blood pressure monitoring. Nursing Standard. 22, 19, 45-48.

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Walsh M, Crumbie A, Reveley S (1999). Nurse Practitioners clinical Skills and Professional Issues. Butterworth Heinemann. Waters A (2007) Numbers add up in staffing formula. Nursing Standard. 22, 8, 12-13. Watkinson S, Seewoodhary R (2008) Administering eye medications . Nursing Standard. Vol 22 no 27. 51-57 Watkinson S, Seewoodhary R (2008) Ocular complications associated with diabetes mellitus. Nursing Standard. Vol 22 no 18. 42-48 Wardrope J & English B (1998). Musculo-skeletal Problems in Emergency Medicine. Oxford Press. Wardrope J & Smith JAR (1996). The management of wounds and burns. Oxford Press. Waterhouse C (20050 The Glasgow Coma Scale and other neurological observations. Nursing Standard. 19, 33, 56-64. Watkins P (2005) Impetigo: aetiology, complications and treatment options. Nursing Standard. 19, 36, 51-54. Watkins P (2006) Identifying and treating planter warts. Nursing Standard. 20, 42, 5054. Watkinson S, Seewoodhary R (2007) Common conditions and practical considerations in eye care. Nursing Standard. 21, 44, 42-47. Watkinson S, Graham S (2005) Visual impairment in children. Nursing Standard. 19, 51, 58-65. Watts BL, Armstrong B (2001). A randomised controlled trial to determine the effectiveness of double tubigrip in grade 1 and 2 (mild to moderate) ankle sprains. Journal Accident Emergency Medicine. 18:46-50. Welch E (2005) Headache. Nursing Standard. Vol 19. no 24. 45-52 Wells et al (1997) Wells score for deep vein thrombosis. Lancet; 350: 1795-98 White R (2005) The benefits of honey in wound management. Nursing Standard. 20, 10, 57-64. Wilson J Bunnell T (2007) A review of the merits of the nurse practitioner role. Nursing Standard. 21, 18, 35-40. Wilson LA (2005) Urinalysis. Nursing Standard. 19, 35, 51-54. Windle J, Mackway-Jones K (2003). Dont throw triage out with the bathwater. Journal Accident Emergency Medicine. 20:119-120.

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Wood A (2006) Treating minor burns in children. Practice Nurse. Vol 32, Issue 10; pg40 Wood J, Wainwright P (2007) Cardiopulmonary resuscitation: nurses and the law. Nursing Standard. 22, 4, 35-40. Wyatt JP, Illingworth RN, Clancy MJ, Munro P, Robertson CE (1999). Oxford handbook of accident & emergency medicine. Oxford press.

7. Monitoring Compliance and Effectiveness


The process by which the MIU will monitor compliance and effectiveness of the protocols will include: The clinical lead will carry out the audit two yearly to ascertain that the Nurse Practitioners are working within the protocols as per Department of Health regulations. The clinical lead will orchestrate the audit with support from one nurse practitioner and administration from a receptionist The casualty cards used by the MIU are not multidisciplinary and the current year cards are kept in the department or on CDrom. Approximately 10 per cent of the activity will be selected at random to include all the nurse practitioners working in the department at the time. Random selection will be taken from January to December of the year to be audited. The results of the audit will be disseminated to individual nurse practitioners and action planning to improve any areas of weakness the audit highlights.

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

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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 by Clinical and Corporate Services Governance Group

Final Approval on behalf of Plymouth Community Healthcare Final Approval for use: Service Director Name: Michelle Thomas Signature ________________________ Date ___________________________

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APPENDIX A

Staff Distribution Signature Sheet for Handbook of Clinical Protocols


Name: Handbook of Clinical Protocols for MIU Policy No: 588 Statement: I have read the above approved and ratified handbook of clinical protocols and understand its contents. If there are any difficulties regarding implementation or any training or competency needs, I have raised and resolved these with my line manager. I agree to implement and work within the content of the above approved and ratified document. Registered Staff Name Signature Date

On completion of this record, this sheet will be kept by the line manager and become part of the training record.

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Staff Distribution Signature Sheet for Handbook of Clinical Protocols


Name: Handbook of Clinical Protocols for MIU Policy No: 588 Statement: I have read the above approved and ratified handbook of clinical protocols. If there are any difficulties regarding working within them or any HCA training or competency needs, I have raised and resolved these with my line manager. I agree to work under the direction of the Nurse Practitioners and within the above Approved and ratified document.

Unregistered Staff Name

Signature

Date

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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

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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

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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

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Increased

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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

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APPENDIX D. Algorithm care pathway. Patient booked in to MIU Patient triaged (using SOAPE). NO
Is the patients condition/illness within clinical protocols.

YES

Does the patient require immediate medical attention.

Assessment by appropriately trained nurse. Treatment, discharge, refer as per protocol.

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

Apply emergency first aid.

Obtain base line observations. Transfer patient to local A&E by the


quickest route i.e... 999. Send copy of casualty card and all documentation with patient.

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APPENDIX E

Guidelines for Thromboprophylaxis in Adult Patients Immobilised in a Lower Limb Cast


Adults 16 or over who are discharged in a lower limb cast should be considered for thromboprophylaxis.

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)

N.B. Consult haematologist if patient has longstanding blood disease.

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:

Indication for Enoxaparin Dose Duration of course Renal function (the maximum dose in severe renal impairment (CrCl <30ml/min) is 20mg daily) Baseline platelet count and U&Es Ask GP to repeat FBC in 5-7 & 12-14 days (give dates) Explain it is for the detection of heparin induced thrombocytopenia

Prescribing Patients who require Enoxaparin should have the first dose in the ED. They will continue treatment for the duration of immobilisation e.g. 6 weeks.

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Please complete a green outpatient prescription form for the patient. Prescribe Enoxaparin for as long as the patient is likely to remain in plaster e.g. 5-6 weeks. Give the prescription to the patient. They will need to go to our pharmacy during opening hours to collect their prescription.

Continuation of Care For those who feel able to self inject, teach them how to do it. Patients have to give their next injection 24 hours after the dose given in the ED. This is a strict prescribing time. However, if it is very inconvenient then it can be given 3hrs either side of this time. They can continue giving Enoxaparin 3hrs either side of the previous days dose until a more convenient time is reached. For those who feel unable to self-inject, Devondoc Referral Team need to be contacted on 01392 822344 8am 10pm 7 days a week, or out of these hours 08456 710270, to inform them that the patient is on Enoxaparin and will need district nursing input. Devondoc will arrange for the district nurse to go in the following day. If this time is inconvenient the district nurse can go in 3hrs either side of the prescribed time. Patients will be encouraged to self inject. They can continue giving Enoxaparin 3hrs either side of the previous days dose until a more convenient time is reached.

You will need to fill out the blue Community Prescription Form to give to the patient so that the district nurse knows what to give. Give the patient a blue satchel containing all their injection kit (kept in draw in plaster room).

Over the Weekend

Follow the guidelines above. We should give the first dose in the ED. If the patient cant self inject they will need to return to the ED for their subsequent doses of Enoxaparin, until the district nurse can take over. Write the subsequent doses on the pink prescription form so the patient does not have to wait to see a doctor on their return visits to the ED Please write the rest of the prescription on the Community Prescription Card for the patient to give to the district nurse The patient must go to pharmacy during opening hours with their green outpatient prescription form to get the rest of their prescription

Refer to fracture clinic/other appropriate clinic for follow up as usual. D Boon Consultant in Emergency Medicine Anita Trehane Sister in Emergency Medicine

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APPENDIX F

Falls Risk Assessment Tool Surname .. Hospital Number .. First Name .. Date of Birth Consultant/GP. .. Screening of Falls Risk in Older People Falls Risk Assessment Tool (FRAT) Part One. For multi-professional use Notes for users: 1. Complete the form below 2. If there is a positive response to three or more questions on the form this predicts a further Fall in the next 6 months. Please refer to GP for attention of District Nurse / Community Matron YES 1. 2. 3. Is there is a history of any Fall in the previous year? NO

Is the patient/client on 4 or more different medications per day? Does the patient/client have a diagnosis of stroke or Parkinsons disease

4.

Does the patient/client report any problems with their balance?

5.

Is the patient/client unable to rise from a chair of knee height without using their arms?

Referrers Details Completed by: (Print)...Designation Contact no. Date/Time..Signature

Name tel

Ref: This guidance has been derived from longitudinal studies of factors predicting falls in older people. Originally designed by Queen Mary College, University of London and based on Plymouth PCH & SW Ambulance Service FRAT 1 form

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APPENDIX G

Request for Images to be copied to CD


(One electronic form is required for each patient - to be found on shared drive)

Patients images form part of the Patients record and are subject to all Trust policies regarding access to health records. Details of Requester
Name Job Title Ward/Department Hospital Contact Telephone Number/Bleep E-mail Address

Details of Images Required


Event No Patient ID Date of Exam

Why CD is required?
Patients continuing care is out of district (please state in other box where) Images required for research purposes Images required for research purposes as part of commercial trial Patient has denied consent for images to be stored in Data Centre Images required for legal purposes Other
(Explain)

Patient Consent
Patient consent has been given Patient consent has NOT been given

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APPENDIX H

REI CLINICAL PROTOCOLS


Royal Eye Infirmary Plymouth Hospitals NHS Trust Ophthalmic Clinical Practices 1. Recording of visual activity 2. Examination of the eye 3. Irrigation of the eye 4. Applying a pad to the eye 5. Removal of corneal foreign bodies 6. Removal of conjunctival foreign bodies 7. Taking conjunctival swabs 8. Schirmers tear test 9. Epilation of lashes 10. Dry heat application 11. Lacrimal sac washout 12. Dressing the eye 13. First dressing procedure 14. Insertion/removal of prosthesis 15. Strapping of entropion 16. Inserting and removing contact lenses 17. Administration of local anaesthetic 18. Incision and curettage of a cyst 19. Treatment of arc eye 20. Applanation Tonometry 21. Removal of lid sutures see manual of Royal Marsden Clinical Nursing Procedures Sixth Edition pages 828-829 22. Nurse Led Pre-Operative Clinics 23. Pre-operative clinic (Nurse & Doctor) 24. Nurse Led 1st day post-operative dressing 25. Instillation of eye drops 26. Instillation of eye ointment 27. Administration of subcutaneous injection of Botulinum Toxin

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PLYMOUTH HOSPITALS TRUST ROYAL EYE INFORMARY Clinical Practice No: 1 Recording of Visual Activity Indications: 1. 2. Visual activity is measured for two reasons Medical to monitor the degree of distance vision Legal safeguard for patient and practitioner (Nurse or Doctor)

Types of Charts to measure distance vision: Snellens Chart The E Test Kays Picture Test Sheridan Gardner The Chart This is a flat wall-mounted illuminated box. The letters on the chart are of a specific size and type. They are arranged in size order, the top letter is of such a size and proportion that it can be read by a normal eye at 60 meters, as the patient reads down the lines, the letters become correspondingly smaller. Visual acuity is expressed as a fraction. The Numerator top letter Always being the distance at which the test is performed 6 3 2 1 = = = = 6 meters 3 meters 2 meters 1 meter

The Denominator bottom letter The bottom letter indicates the last line read correctly and presents the distance that the letter should be read by the normal eye. 60 36 24 18 12 9 6 5

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ACTION 1. Sit patient comfortably 6 meters from the chart/ or 3 meters reflected. 2. Ask patient to put distance glasses on if worn 3. Record the visual acuity of the eye that the patient states is weaker or injured or causing problems. Cover the unaffected Eye completely using a small square of paper/card. Do not press on eye Request the patient to read from the top of the chart with the affected eye. Note how far they can read. Note any letters missed or misread, add or subtract as necessary i.e.6/24 + 2, 6/12 3. 5. Cover the affected eye completely with a small square of paper/card and repeat the above procedure 6. Record the visual acuity and compare readings with the previous recordings if applicable 7. If the reading is less than 6/9 repeat with pinhole Category 1 Problem Failure to read the top letters at 9 meters Failure to read 1/60. Failure to count fingers Failure to count fingers Failure to perceive light If an artificial eye is worn. If the pupil is dilated If patient has recently undergone Opthalmic surgery

RATIONALE The designated distance necessary for recording. Distance vision To obtain visual acuity with correct refraction To ensure the patients comfort and to reduce any error when recording visual acuity To obtain the correct reading

To obtain an accurate measurement of distance vision of the unaffected eye To monitor differences and detect trends. Any irregularities should be Brought to the attention of the appropriate personnel. This minimises the effect of a refractive error

Suggested Actions The nurse walks towards the patient with Sheriden Gardner chart, one meter at a time until the letter can be red. It is recorded as5/60, 4/60, 3/60, /60. The patient is asked to count fingers at a distance of 0.9m, 0.6m, 0.3m and this is recorded as (CF) counting fingers The patient is asked to observe the nurses hand moving at a distance of 0.3m. This is distance of 0.3m. This is recorded as (HM) hand movements A light is shone in the patients eye from different directions. If the light can be seen it is recorded as (PL) perception of light It is recorded as (NPL) no perception of light This is recorded in the notes for documentation and staff awareness The visual acuity is recorded using pinhole (see Addendum) The vision should be checked Without old prescription glasses as these are probably the wrong refraction. The vision should then be checked with pinhole to check possible corrected visual acuity

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Procedure for taking Visual Acuity using the STYCAR/Sheridan Gardner

Indications: For patients who cannot read or who are unfamiliar with the alphabet - It will require two people to record. Equipment: Stycar consist of: 1. Ring bound cards containing the Snellen type letters equal in size to the Snellens type letters on the illuminated box. 2. A small plastic card containing the nine letters. ACTION 1. Explain procedure to patient 2. Sit the patient comfortably beside the nurse assistant. The patient is given a card showing the nine Snellens letters 3. The second nurse stands 6 meters from the patient ensuring good illumination present on the ring bound cards 4. Record the visual acuity of the affected eye first. Cover the unaffected eye completely using a small square card. Do not press on the eye 5. The second nurse shows the patient the largest letter on the ring bound card (corresponding to 6/60 size Snellens letter) The patient is requested to point to the shape on the card he/she is holding Note any letter missed or unrecognised. The loose leaf card is turned on completion of a letter successfully recognised. The patient is shown letters in diminishing size corresponding to those on the Snellens chart 6. Cover the affected eye completely with a small a small square of paper/card and repeat the above procedure 7. Record the visual acuity and compare reading with the previous recordings. it is recorded in the same way as the procedure of the Snellens chart 8. If the pupil is dilated the procedure is RATIONALE A well-informed patient is more likely to comply with the procedure To ensure accurate supervision whilst maintaining a relaxed environment The designated distance necessary for recorded distance vision. To produce Sufficient light to illuminate the ring bound cards To ensure the patients comfort and to reduce any error when recording visual acuity To obtain an accurate reading.

To obtain an accurate measurement of measurement of eye To monitor differences and detect trends Any irregularities should be brought to the attention of the appropriate personnel The nurse holding the ring bound card

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repeated using a pinhole. Failure to read the top letter at 6 meters

moves towards the patient one meter at a time in the same way as the procedure of taking visual acuity with the Snellen or E Type chart

A Pinhole Disc A pinhole disc is a round black disc with a minute hole through the centre. This is used to cover the eye and the patient is asked to look trough the small hole and read the chart. The other eye is completely covered. The vision is recorded i.e. 6/6 i/c PH.

REFERENCES A Synopsis in Ophthalmology JLC Martin Doyle, Martin H Kemp p2 Kenneth Wybar & Malcolm Kerr Muir p5 Bailtieres Concise Medical Textbooks Ena Percy, W A M Smith p37 Second Edition 1997 Rosalind Stollery Pub. Blackwell Science p. 23-25 Second Edition 1995 John P Berry & Andrew B Tullo Pub. Chapman and Hall p.3

Ophthalmology

Ophthalmology Part 2

Ophthalmic Nursing

Care of the Ophthalmic Patient

August 2000 Sister V Brotherton Sister S Williams Reviewed November 2001/2010 Sister V Brotherton Rgn S Gregson Rgn L Prime LNN Rgn A Triggol Sister S Williams

PLYMOUTH HOSPITALS TRUST

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ROYAL EYE INFIRMARY Clinical Practice No: 2 Examination of the Eye To determine the condition. Light/torch Tissues Anaesthetic Guttae Proxymethacaine 0.5% Minims When the patient is in extreme pain and discomfort an anaesthetic drop may be needed to enable the eye to be examined. Staining agent G. Fluorescein 2% minims or Fluoret strips Guttae Sodium Chloride 0.9& minims Cotton buds RATIONALE A well informed patient is more likely to comply with treatment To detect a variation between the two eyes. For legal purposes This will often help to identify the problem This ensures comfort for the patient and convenience for the nurse This ensures comfort for the patient and convenience for the nurse (see Addendum 1) (see Addendum 2)

Reason: Equipment:

ACTION 1. Explain procedure to patient 2. Visual acuity must always be checked (see CP No 1) and recorded 3. A full nursing assessment using appropriate model Oram and Riehls 4. The eye is best examined standing behind the patient with his/her head well supported 5. Commence the examination in a logical and systematic manner noting each structure in turn from the outside inwards Face Eyelashes Eyelids to include lid eversion Punctum Conjunctiva Sclera Cornea Anterior Chamber Iris Pupil 6. Note observations Pain Redness Swelling Dislike if light (photophobia) Watering (epiphora) Discolouration Misalignment FB - Corneal, subtarsal, conjunctival or

Presence of one or more of the observations may indicate injury or disease

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intra-ocular

Addendum 1 Eversion of the Upper Lid The patient is asked to look down. The nurse holds the lashes between her forefinger and thumb, the lid is drawn downward and away from the eyeball, a finger of the other hand or cotton bud is used to depress the upper margin of the tarsal plate and the eyelid is turned over (see diagram below) Diagram to show eversion of the upper lid

N.B Double eversion of the upper lid may be necessary in certain circumstances, e.g. solid lime particles. Refer to Medical Officer in these circumstances. Addendum 2 Examination of the Eye Structure Face Eyelashes Eyelids Must include lid eversion (see Addendum 1) Normal Symmetrical Irregular rows of Short stout hairs turning outwards Eyelids in good apposition Abnormal Asymmetry may denote an underlying problem Turning in of eyelashes Trichiasis, causing irritation to the eye Note abnormalities:Failure to close together Infections, inflammations, Injuries, discharges, swelling, Bruising, lacerations Lid turning in Entropian

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Punctum

Conjunctiva

To include the balbar conjunctiva and the fornices

Two small openings Situated on the inner aspect of the top and the bottom lids Loose colourless membrane covering the sclera and the inside of the eyelids

Lid turning out Ectropian Blockage may cause watery eyes Epiphora Note Lacerations. Note Hyperaemia, Chemosis infections, Inflammations allergies, foreign body, Subconjunctival haemorrhage lacerations. Note localised inflammation thinning or thickening of the layers, colour. Trauma. Note oedema, abrasions, Foreign bodies, opacities, trauma.

Sclera

White of the eye ball

Cornea

Clear and bright and Reflect the light

DO NOT STAIN THE CORNEA IN THE FOLLOWING CASES: 1. When a perforating injury is suspected (see Addendum 3) 2. When a soft contact lens is in situ. 3. Following the removal of a corneal foreign body. Staining the cornea may detect epithelial damage caused by abrasions or ulcerations. Anterior Note contents Blood Hyohaema. Note depth, deep or Chamber shallow. Compare with the Pus Hypopyon Cells Keratic precipitates other eye Foreign Bodies Lens implants Iris Well defined pattern and colour. Brisk reaction to light Round shape Position should be central Colour compare with the other eye clarity and pattern. Note lacerations, holes, Iridodialysis. Reaction to light may be sluggish or fixed. The pupil May be irregular in shape, could indicate syneachias, oral pupil, could indicate acute glaucoma. N.B Drugs may altar the shape of the pupil. N.B Previous ocular surgery may altar the shape of pupil.

Pupil

Addendum 3 Intraocular Foreign Bodies Foreign bodies may enter the eye with speed and penetrate the globe through a selfsealing wound. This is always possible if Hammer and Chisel history is obtained. Look for intra-

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lenticular foreign bodies. Minute air bubbles in the anterior chamber may be the only indication of a concealed perforating injury. Look for conjunctival haemorrhage which may conceal a scleral perforation. REFERENCES A Synopsis of Ophthalmology JLC Martin-Doyle, MH Kemp pages 1-7 5th Edition, John Wright & Sons D Vaughan, T Ashbury pages 14-16 10th Edition, Lange Publications Narciss Ikhravi Published, Butterworth & Heinemann pages 39-55 2nd Edition 1997 Published, Blackwell Science pages 2729 Rosalind Stollery FCE Rooke, PJ Rothwell, DF Woodhouse pages 43-44 Published 1980, Churchill Livingstone

General Ophthalmology

Manual of Primary Eye Care 1997

Ophthalmic Nursing

Ophthalmic Nursing

Its Practice & Management

August 2000/2010 Sister Brotherton Sister Williams Reviewed November 2001 Sister V Brotherton Rgn S Gregson Rgn L Prime LNN Rgn A Triggol Sister S Williams

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PLYMOUTH HOSPITALS TRUSY ROYAL EYE INFORMARY Clinical Practice No: 3 Eye Irrigation For removal of harmful substances from the eye.

Reason:

Equipment: Local Anaesthetic Proxymethacaine 0.5% Minims Irrigation fluid (usually sterile normal saline 500ml bag/150ml) bottle (but in an emergency tap water may be used 150ml) Receiver Plastic cape IV giving set IV drip stand pH Indicators Tissues ACTION 1. Remove irrigation fluid from warming cabinet 2. Explanation to patient. 3. Assist the patient into the appropriate position Head comfortably supported with chin almost horizontal. Head inclined to the side of the eye to be treated. 4. Instill local anaesthetic drops 5. Test the pH of the eye. Insert small strip of pH indicator into lower fornix for 5 seconds 6. Remove any discharge/debris from the eye by swabbing, using tissues, cotton buds or gauze. 7. Position the plastic cape. 8. Ask the patient to hold the receiver against his/her cheek below the eye being treated 9. Hold the patients eyelids apart using your first and second fingers against the orbital ridge 10. Do not press the eyeball. RATIONALE Tepid fluid will be more comfortable for the patient. The solution should be poured across the inner aspect of the nurses wrist to test the temperature. A well informed patient is more likely to comply with treatment For patient comfort

For patient comfort To find out if acid or alkali present. To prevent washing the discharge down the lacrimal duct or across the cheek To protect patients clothing To collect irrigation as it runs away from the eye The patient will be unable to hold his eye Open once irrigation starts To avoid causing the patient discomfort or

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pain 11. Warn the patient that the flow of solution is going to start and pour a little onto his/her cheek first To wash away from the lacrimal puntum 12. Direct the flow of fluid from the nasal corner outwards at a distance of 2.5cm from the patient. 13. Ask the patient to look up, down and to To ensure that the whole area is washed either side while irrigating. To remove harmful substance from the tarsal plate 14. Evert eyelids (see Addendum 1) Clinical Procedure No 2 15. Keep the flow of irrigation fluid constant 16. When the eye has been thoroughly irrigated ask the patient to close their eyes and use a tissue to dry the lids 17. Take the receiver from the patient and If the receiver is removed first solution dry his/her cheek May run down the patients neck 18. Blow nose. To clear nasal lacrimal ducts 19. Check pH after period of non-irrigation Irrigation is ceased altogether repeat i.e. two consecutive tests 20 minutes apart before Irrigation is ceased altogether. 20. Make the patient comfortable. 21. Remove and dispose of equipment 22. Record procedure in the appropriate documents. REFERENCES Immediate Eye Care Ragge and Easty Wolfe Pub Ltd 1990 Page 251 The Royal Marsden Hospital Harper Row Pub. 1985 pages 173-175 P Garland Faber & Faber Pages 50-58 1969 2nd Edition Vera H Darling, Margaret R Thorpe Pages 17-18 Bailliere Tindall To avoid infection. To ensure accurate records for future reference

Manual of Clinical Nursing Policies And Procedures

Ophthalmic Nursing

Ophthalmic Nursing

August 2000 Sister Brotherton

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Sister Williams Reviewed November 2001 Sister V Brotherton Rgn S Gregson Rgn L Prime LNN Rgn A Triggol Sister S Williams

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PLYMOUTH HOSPITALS TRUSY ROYAL EYE INFORMARY Clinical Practice No: 4 Applying a Pad to the Eye

Indications: Trauma Surgery After removal of Corneal Foreign Body After subconjunctival Infection Corneal abrasions Insensitive cornea

Equipment: Two eye pads Tape Cartella shield Treatment ACTION 1. Explain procedure to patient. Ensure patient is not driving RATIONALE A well informed patient is more relaxed. It is dangerous to drive with an eye pad in situ 2. Instil prescribed treatment To ensure patient receives treatment prescribed and aid recovery 3. Ensure the eyelids are closed On To prevent corneal damage by cornea occasions it may Be necessary to tape lids rubbing on pad 4. Apply pads Fold one pad in half. To fill socket area and therefore prevent eye opening 5. Apply full pad Gives added pressure to keep eye closed 6. Apply suitable tape checking To ensure pad does not fall off previously for allergies. 7. Ensure tape ends are turned in, leaving To prevent excoriation of skin when a tab removing 8. Apply bandage if required. See Oph Further pressure. If allergic to tape. If skin Proc no. 5. damaged and unable to use tape 9. Reinforce patient education To maximise patient co operation and aid healing process 10. Sign and record procedure in the case Record that this particular procedure has notes been carried out REFERENCES

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Care of the Ophthalmic Patient

John P Perry & Andrew B Tullo 1995.Pub. Chapman & Hall p77 Narciss Okhravi Pub. Butterworth & Heinemann p130

Manual of primary Eye Care 1997

August 2000 Sister Brotherton Sister Williams Reviewed November 2001 Sister V Brotherton Rgn S Gregson Rgn L Prime LNN Rgn A Triggol Sister S Williams

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PLYMOUTH HOSPITALS TRUSY ROYAL EYE INFORMARY Clinical Practice No: 5 Removal of Corneal Foreign Bodies (Procedure to be undertaken by Ophthalmic Nurse Practitioners)

Indications: To relieve pain and discomfort. To prevent complications and ulceration to the cornea. Equipment: Local anaesthetic Proxymethacaine 0.5% Minims Slit lamp Orange needle 25g Green needle 21g

ACTION 1. Elicit history i.e. home, working on the car, at work. hammer and chisel, grinding and obtain where possible the time of the injury 2. Corneal Foreign Body Explain the procedure to the patient

RATIONALE To appreciate the full extent of the injury and for legal requirements. It is essential to promote and maintain a relaxed atmosphere. It is not therefore recommended that the patient is fully informed how the foreign body will be removed. It is considered unnecessary that the word needle is used as this would cause the patient undue alarm Legal requirement To assist in patient compliance For future reference This will ensure surface anaesthesia in3040 seconds and will last for 20-40 minutes To prevent further injury whilst foreign body being removed To prevent further injury to the cornea

3. Obtain a verbal consent 4. Sit the patient comfortably at the slit lamp 5. Document the position of the foreign body in patient notes 6. Instil local anaesthetic 1-2 drops Proxymethacaine 7. Ask the patient to fix his/her gaze on one spot and not move the eye 8. Remove the foreign body using 25g or 21g sterile needle, held on a 2ml syringe if preferred, remove the foreign body with a picking action never sweep across the

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cornea but lift off using the extreme point only. Never point the needle towards the eye but approach the eye with the shaft of the needle parallel (tangential) to the surface 9. Check carefully that removal is complete 10. Do not stain the cornea with fluorescein Follow NP protocol or refer to Doctor if clinically indicated 11. If rust remains using needle to remove Review after 3-5 days and complete the removal of the rust

To prevent further irrigation and complications This is conductive to subsequent corneal ulcers To allow time for rust to migrate to corneal surface. Patient choice to encourage compliance

REFERENCES Immediate Eye Care Ragge & Easty Wolfe Pub. Ltd 1990 Page 213 2nd Edition 1997 Rosalind Stollery Pub. Blackwell Science Pages 33-34 & 219 Douglas J Rhea Mark F Pyfer Lippincott Williams & Wilkins 3rd Edition 1999 Pages 24-26

Ophthalmic Nursing

Wills Eye Manual

August 2000 Sister Brotherton Sister Williams Reviewed November 2001 Sister V Brotherton Rgn S Gregson Rgn L Prime LNN Rgn A Triggol Sister S Williams Reviewed September 2005 Sister Brotherton Sister Williams

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PLYMOUTH HOSPITALS TRUSY ROYAL EYE INFORMARY Clinical Practice No: 17 Administration of a Local Anaesthetic Reason: To inject a prescribed amount/drug of local anaesthetic prior to an invasive lid procedure. Indications: To permit a pain-free procedure. Equipment: 2ml Syringe 19 or 21g needle 25 or 27g needle (for administration) (for drawing up) Consent form Patients records Skin Cleaners Prescribed drug Gauze Steret Local Anaesthetic Proxymethacaine 0.5% Felt tip pen

ACTION 1. explain procedure to patient and obtain consent 2. Position as comfortable for patient 3. Clean technique to be strictly observed 4. Instil local anaesthetic drops into the correct eye 5. Check drugs against patients records/ treatment cards 6. For multi dose Vial: inspect solution for cloudiness or particular matter Check expiry date 7. Clean the rubber cap with the chosen antiseptic and let it dry 8. Withdraw the prescribed amount of solution (usually 1.5-2mls) and inspect for pieces of rubber, which may have cored out of the cap 9. Tap the syringe to remove any air bubbles. Expel air 10. Change the needle

RATIONALE A well-informed patient is more relaxed To obtain best position for the procedure to be performed ensuring patients comfort To avoid infection of the injected site To anaesthetise the injected site and surface of the eye To ensure that the patient is given the correct drug in the prescribed dose To prevent patient from receiving an unstable or contaminated drug To prevent bacterial contamination of the drug To prevent the injection of foreign matter into the patient To ensure that the correct amount of drug in the syringe To reduce the risk of infection. To avoid possible trauma to the patient if needle has been barbed To ensure that the correct size of needle is used for the

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11. Clean the site as per local policy and mark site of cyst on outer lid checking against patients records 12. Ask patient to fix and hold gaze. Down for upper Lid, up for upper lid. 13. Inform the patient the injection will sting 14. Insert the needle into the lid at a 30 angle at the upper margin of the upper lid tarsus and the lower tarsal margin in the lower lid. Pull back the plunger if no blood is aspirated, depress the plunger and inject drug slowly. The injecting needle is carried forward to the lid margin on either side of the chalazion 15. With the needle slowly and gently asking the patient to close the eye 16. Ask patient to hold gauze to apply pressure to site of injection 17. Allow 5 minutes for local anaesthetic to take effect and check for effectiveness before commencing invasive procedure. 18. Record and sign patients records

injection To reduce the number of pathogens introduced into the skin by the needle at time of insertion and to ensure incision of correct area To expose sire of injection, to prevent damage to cornea Patient is prepared for discomfort To confirm that the needle is in correct position, to prevent pain filtration of drug

To ensure correct application To reduce swelling and maximise absorption To ensure pain-free invasive procedure To document procedure has been performed

REFERENCES The Royal Marsden Hospital Manual of Clinical Nursing Procedures 6th Edition August 200 Reviewed December 2001 Sister S Williams S Cooper Reviewed September 2005 Sister S Williams S Cooper Lisa Dougherty & Sara Lister Pages 206-208 Pub. Blackwall

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PLYMOUTH HOSPITALS TRUST ROYAL EYE INFORMARY Clinical Practice No: 17 Treatment of ARC Eye ACTION 1. Explanation to the patient 2. Assist the patient into the appropriate position head comfortably supported 3. Instil Guttae Proxymmethacaine 0.5% STAT 4. Apply cold pads 5. Refer to Nurse Practitioner / Medical Staff REFERENCES Ophthalmic Nursing 2nd Edition 1997 Rosalind Stollery Pub. Blackwell Science Page 218 RATIONALE A well informed patient is more likely to comply with treatment For patient comfort For effective relief of discomfort For effective relief of discomfort For further treatment

August 200 Sister Brotherton Sister Williams Reviewed December 2001 Sister V Brotherton Rgn S Gregson Rgn L Prime LNN Rgn A Triggol Sister S Williams Reviewed September 2005 Sister S Williams Sister V Brotherton

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PLYMOUTH HOSPITALS TRUSY ROYAL EYE INFORMARY Clinical Practice No: 25 Guidelines; - Instillation of Eye Drops Equipment: 1. Prescription;- Check in notes or against drop prescription chart. 2. Access to either alcohol hand gel or hand washing facilities 3. Tissues.

PROCEDURE ACTION 1. Explain and discuss procedure with patient Describe side effects and advise against his/her valid driving, if appropriate 2. If there is any discharge, record in notes (HCA TO CHECK WITH NURSE) Take a swab and lean if required (Clinical policy no: 8) 3. Check the following: a) It is correct patient b) It is the correct eye c) Expiry date on the medication d) It is the correct medication e) It is the correct strength of medication. f) The time and date of instillation are correct. g) The date and commencement of treatment. h) The medical staff have signed the prescription 4. Assist patient into correct position i.e. head well supported and tilted back 5. Wash hands thoroughly using soap or RATIONALE To ensure that the patient understands the procedure and gives consent To remove any infected material and thus ensure adequate drop absorption

To ensure that appropriate drops are instilled into correct patient To avoid cross infection and instillation of drug into wrong eye To ensure expiry date has not been reached To comply with P.H.T Policy for the safe and secure handling of medicines.

To ensure drops are instilled beneath the lower lid into the fornix and to avoid any excess solution running down the cheek. Asepsis is essential, particularly when the

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alcohol hand rub, making sure hands are completely dry

patient has a damaged eye or has just had an operation on the eye. Infection can lead to the loss of an eye. 6. Place tissue/swab on the lower lid To absorb any excess solution which May against the lid margin be irritating to the surrounding skin. 7. Ask the patient to look up, instil the drop This opens the eye and allows the drops to be instilled into outer side of the lower into the lower fornix, between the middle fornix and not directly onto the very and outer third of the eye sensitive cornea 8. Ask the patient to gently close the eye To ensure the absorption of the fluid and Keep the tissue/swab on the lower lid avoid excess running down the cheek. 9. Make the patient comfortable 10. Remove and dispose of equipment To avoid cross infection 11. Wash hands with bacterial soap and water or bacterial alcohol hand rub and then dry hands 12. Record the procedure in the To monitor trends and fluctuations. appropriate documents

REFERENCES Care of the Ophthalmic Patient 2nd Edition (1996) Chapman & Hall, London Perry J.B, Tullo A.B Pages 74-75 Edited by Lisa Dougherty & Sarah Lister. Pages 555-6 & 566 Pub. Blackwell

The Royal Marsden Hospital Manual of Clinical Nurses Procedure 6th Edition

August 2001 SN J Ashton Sister Brotherton SN J Johnson Sister Williams

Reviewed September 2005 Sister S Williams Sister V Brotherton

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PLYMOUTH HOSPITALS TRUSY ROYAL EYE INFORMARY Clinical Practice No: 26 Guidelines; - Instillation of Eye Ointment Equipment: Appropriate eye ointment. (Any preparation must be checked against the doctors prescription) Access to alcohol hand gel and hand washing facilities.

PROCEDURE ACTION 1. Explain and discuss the procedure with the patient 2. If there is any discharge, record in notes (HCA TO CHECK WITH NURSE) Take a swab and clean if required(Clinical Policy no: 8) 3. Check the following:a) It is the correct patient b) It is the correct eye c) Expiry date on tube d) It is the correct ointment e) It is the correct strength of ointment f) The time and date of application is correct. g) The date of commence of treatment. h) The medical staff have signed the prescription. 4. Wash hands thoroughly using bacterial soap and water or bactericidal alcohol hand rub and then dry hands 5. Place tissue or swab on the lower lid against the lid margin 6. Slightly evert the lower lid by pulling on the tissue/swab. Ask the patient to look up immediately before applying the ointment. 7. Apply the ointment by gently squeezing RATIONALE To ensure that the patient understands the procedure and gives his/her valid consent To remove any infected material and previous ointment

To ensure that the patient understands the procedure and gives consent To avoid cross infection and application of ointment into wrong eye. To ensure expiry date has not been reached. To comply with P.H.T Policy for the safe and secure handling of medicines.

To avoid infection To absorb excess ointment which may be irritating to surrounding skin. To allow the application to be made inside

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the tube and with the nozzle 2.5cm above lower lid. Insert a small stream of ointment the into the lower fornix from the inner to the outer aspect 8. Ask the patient to close the eye gently and remove excess ointment with a tissue/swab 9. Warn the patient that when the eye is opened Vision will be a little blurred for a few minutes 10. Make the patient comfortable 11. Remove and dispose of equipment. 12. Wash hands with soap and water or use alcohol hand gel. 13. Record the procedure in the appropriate documents

the lower lid into the lower fornix.

To avoid possible contamination and trauma To avoid excess ointment which may be irritating to the surrounding skin. To prepare patient and avoid anxiety.

To avoid infection To monitor trends and fluctuations.

REFERENCES Care of the Ophthalmic Patient 2nd Edition 1996 John P Perry & Andrew B Tullo Pub. Chapman & Hall Pages 74-75 Edited by Lisa Dougherty & Sarah Lister Pages 555-6 & 567-8 Pub. Blackwell

The Royal Marsden Hospital Manual of Clinical Nurses Procedure 6th Edition

August 2001 SN J Ashton Sister Brotherton SN J Johnson Sister Williams

Reviewed September 2005 Sister S Williams Sister V Brotherton

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APPENDIX I
2010 Adult Documentation Audit Tool Date of Audit: Sample Size: ( ) casualty cards, at random, per nurse practitioners working in MIU. Indicator Documented Not documented 1.All Patient demographic information noted on front of card -name, address or temp address, postcode, telephone number, DOB, ethnic group, GP name , address and telephone number, gender, marital status, occupation. Must be 100% to be 'yes documented' 2.Time of patients arrival and first contact with the service using 24 hour clock 3.Is the casualty card Legible and written in black ink and free from ditto marks 4.Time practitioner commenced consultation using 24 hour clock 5.All casualty card pages dated and chronologically 6.Consent for treatment or sharing of information fully documented 7. History of injury - What? Why When? From whom e.g. patient/carer 8. Past medial injury - when appropriate 9.Allergy status 10.Tetanus status - when breach of skin present 11. Current Medication - if any, Nil documented if patient not taking any medicines 12. Examination findings documented 13.Negative findings documented, if any 14.X-ray noted, if taken 15. Time patient sent to x-ray using 24 hour clock 16. Time patient returned from x-ray using 24 hour clock 17. Diagnosis or clinicians impression documented if unable to diagnose condition. 18. Treatment given in full and duration i.e. rest 3//7 if no improvement see GP. 19. Drugs specified to include advice on using own/over the counter drugs i.e. patients own Paracetamol. 20. Disposal of patient documented If R/V must state where and when. 21. Transfer: Type of transport documented 22. Time transport ordered documented using 24 hour clock 23.Time transport arrived documented using 24 hour clock 24.Times patients discharged from unit using 24 hour clock 25.Signature of each Practitioner who has contact with patient 26.Practioner named printed in Full who has contact with patient Comments (note what is not documented)

27.Designation of Practitioner who has contact


with patient

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28. Only locally agreed abbreviations linked to clinical protocols used ( list can be found in folder or Healthnet). No other abbreviations used. 29.Are mistakes crossed through with a single line signed and dated 30.Are all pages of the casualty card fully Identified with unique patient identifier e.g. NHS number, DOB, Epex number 31. Are all the coding boxes completed at the reverse of the casualty card that correlate with the clinical records, investigations undertaken and treatments supplied, discharge transport , discharge times (using 24 hour clock) and disposal or referrals, initial data inputting. 32. GP Letter written and sent 33. Does the patient's attendance correlate with the ePEX contacts records? 34. Casualty Card stored according to Record Keeping policy - filing system, all casualty cards securely attached and stored in a lockable cabinet within a locked room (note what is not documented) (note what is not documented)

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APPENDIX J ADVICE LEAFLETS FOR SHOULDER MANAGEMENT Shoulder Fracture Information & Advice Shoulder Injury Exercise Information & Advice Shoulder Injury Information & Advice

All policies are required to be electronically signed by the Lead Director (the policy will not be accepted onto Healthnet until the e-signature is received). The proof of signature for all policies is stored in the policies database.

The Lead Director approves this document and any attached appendices. Signed: Title: Date:

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