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Guia d’Intervencions d’Infermeria a Problemes de Salut EAP Can Bou
V 1.2 12/2012 Castelldefels Agents de Salut d’Atenció Primària CASAP 3
© Castelldefels Agents de Salut (CASAP)
Av. Ciutat de Màlaga, 18-20 08860 Castelldefels (Barcelona) Translation by Clara Martí Aguasca
Nursing Interventions Guide to Health Problems - Can Bou EAP
V 1.2 12/2012 Castelldefels Agents de Salut d’Atenció Primària CASAP 5
Authors and contributors ............................................................................................................................................ 7
Circuit care demands............................................................................................................................................... 15
Acute health problems Oral thrush ............................................................... 18 Emergency contraception ................................... 20 Burn ........................................................................... 22 Anxiety attack ........................................................ 24 Diarrhea ................................................................... 26 Blood pressure elevation ....................................... 28 Epistaxis .................................................................... 30 Wound .................................................................... 32 Herpes ...................................................................... 34 Dermal lesion of skin folds ..................................... 36 Sore throat ............................................................... 38 Backache ............................................................... 40
Toothache ......................................................... 42 Distress when urinating .................................... 44 Animal bite ........................................................ 46 Stye ..................................................................... 48 Bite ...................................................................... 50 Mosquito bite .................................................... 52 Allergic reaction ............................................... 54 Respiratory symptoms in upper airways ....... 56 Sprained ankle .................................................. 58 Trauma .............................................................. 60 Whitlows ............................................................. 62
Urgent health problems
Aggressions ............................................................. 66 Cardiac arrest ......................................................... 68 Seizures ..................................................................... 70 Heatstroke ............................................................... 72 Severe abdominal pain ........................................ 74 Chest pain ............................................................... 76 Fever > 39º ............................................................... 78 Intoxications ............................................................ 80 Serious eye injury .................................................... 82
Intens headache .............................................. 84 Dizziness .............................................................. 86 Drowning ........................................................... 88 Loss of conscience ........................................... 90 Gastrointestinal bleeding ................................ 92 Traumatic brain injury ...................................... 94 Severe trauma .................................................. 96 Vomiting ............................................................. 98 Anaphylactic shock ....................................... 100
Drugs guide
Analgesics and antipyretics .............................................................................................................................. 105 Antibiotics ............................................................................................................................................................ 107 Topical treatment ............................................................................................................................................... 109 Others .................................................................................................................................................................... 110
Annex Pain scale ............................................................................................................................................................. 113 Radiographic projections .................................................................................................................................. 114 Nursing assessment ............................................................................................................................................. 115 Neurological assessment ................................................................................................................................... 116 Assessment of burn lesions ................................................................................................................................. 117
Bibliography ............................................................................................................................................................. 121
Nursing Interventions Guide to Health Problems - Can Bou EAP
V 1.2 12/2012 Castelldefels Agents de Salut d’Atenció Primària CASAP 7
Direction
Authors: working group of non scheduled demand management
Gascón Ferret, Jordi Gímenez Jordan, Laura Mateo Viladomat, Enric Pavón Rodríguez, Francisca Vilalta García, Susana
Coordination edition Pavón Rodríguez, Francisca
Contributors
Nurses Campoy Sanchez, Ana Casado Montañés, Isabel Fernández Delgado, Maite Fernández Molero, Sònia Hernández Escriche, Carmen Laserna Jimenez, Cristina Malo Verde, Agustina Moya Calaf, Griselda Mulero Madrid, Ana Noguera Argelès, Mª Antònia Osuna Gomera, Yolanda Raventós Jurado, Paola Rodríguez Hernández, Yolanda Sancho Domènec, Laura Tàpia López, Montserrat Torres Roca, Dolors
Doctors Bernades Carulla, Carlos
Bosch Romero, Emilia Chiriac, Ionut Garcia Tristante, Daniel Gomez Fernandez, Claudia Gonzalez Azuara, Sílvia Jareño Sanz, Mª José Manzotti, Carolina Santamaria Martín, Maribel Silvestre Puerto, Víctor
Dentistry Prunera Badosa, Núria
Health administrative Hurtado Colmenero, Natàlia Ibáñez Mancebo, Sandra Madrid Ramón, Miguela Muñoz Roldan, Araceli Osuna Muñoz, Susana Santana Cabrera, Maite Sevillano Palma, Victòria Tello Pérez, Alicia Vilaseca Ortiz Urbina, Maite
Nursing assistant Burgos Casado, Sònia Santana Cabrera, Imma
Reviewers
Amat Camats, Gemma. “Associació d’Infermeria Familiar i Comunitària de Catalunya” (AIFiCC) Flores Mateo, Gemma. “Institut d’Investigació en Atenció Primària” (IDIAP) Morera Castell, Ramon. “Societat Catalana de Medicina Familiar i Comunitària” (CAMFiC)
Technical support and design
authors
Nursing Interventions Guide to Health Problems - Can Bou EAP
V 1.2 12/2012 Castelldefels Agents de Salut d’Atenció Primària CASAP 9
A few years ago we proposed that one of the priority objectives of the primary health care is to solve maximum problems of population with better accessibility. The current economic situation makes it much more necessary to move towards this goal. A few years ago, the Primary Care Team Can Bou and the Consortium Castelldefels Health Agents (CASAP) developed this project which now we present in a new version. The document "Guide of nursing interventions to Health Problems" is the result of a teamwork. At first was based on the scientific evidence for diagnostic and therapeutic procedures and the will to streamline the care process of the known as spontaneous demands. It has served us to promote the integration of customer care professionals as health care professionals in the care process and within the team itself, with nurses and doctors. These are Guidelines based on various documents of scientific rigor, and in turn, the tools to facilitate problem solving by nurses, referred professionals to solve different acute health problems, both to expedite the resolution and being professionals with demonstrated skills. With the experience given us by years of working with this tool, with the review and improvement made through the analysis and the recommendations made by the same professionals who use them daily, we offer this update guideline that we trust you find illuminating, interesting and, over all, useful for the daily task with population that requires our service.
Dr. Antoni Peris i Grao
Family physician - Director Manager Health Center Can Bou
presentation
Nursing Interventions Guide to Health Problems - Can Bou EAP
V 1.2 12/2012 Castelldefels Agents de Salut d’Atenció Primària CASAP 11
Nurses here and abroad have initiated measures to enhance the role of nurses in the care of acute health problems, with the goal of becoming the gateway to the health system and also in giving response to much of the demands presented on the population. It is necessary to adapt activity and resolution capability of the primary attention nurse to these demands for increasing system’s efficiency and sustainability. This project aims to provide all team members, the use of a methodology agreed on circuits, decision making and interventions, based on available scientific evidence and methodological nursing tools. By consensus of the working group and the rest of the team, have been chosen a number of health problems that go straight to the consultation of spontaneous attention. The nurse, after making the assessment, can give the user the right treatment (cure, tips, drug ...) or to quote the reference professional (doctor or nurse) to do the monitoring. To carry through demand management in a efficiently and operationally way, it is necessary to coordinate the actions of the nurse who attends care consultation of spontaneous visits with the receiving of the user by the health administrative team that prioritize and manage demands to the indicated professionals, and also with the team of family physicians and pediatricians who provide support and assistance in cases that require their intervention. Other health problems, considered as emergencies, pass to the consultation of spontaneous attention directly, where they are valued by the nurse who once made the history, contact the doctor on call and will agree the action to follow. How was the document elaborated The first document was edited in September 2007. After 5 years, we have made a second edition, with a complete overhaul of the protocols, circuits and treatments according to the latest scientific evidence. Health problems, described according signs and symptoms, have been prioritized from a selection of the most frequent problems, which most of the nurses working in primary care resolve in daily practice. In this review we have identified 23 health problems solvable by nurses and 18 emergency possible intervention. Each health problem is divided into three sections: the first contains a brief definition of the problem, the second describes an algorithm of actuation which includes the history, assessment, intervention, alert causes and revisiting criteria and, finally, a third section includes most common nursing diagnoses NANDA (Norh American nursing Diagnosis Association).for each common health problem and possible nursing interventions- NIC (nursing Interventions Classification). NIC’s are divided into two blocks: the first block found those deemed essential or primary to be made to make the situation of health, and in the second block, the secondary or optional, that can be performed depending on the situation and nurse assessment. In the Annex there is a guide of all those drugs which are indicated in the protocols, indicating the active ingredient, presentation, route of administration, trademarks and properties of each, the pain scales most commonly used, the radiological projections, nursing assessment according to V.Herderson pattern and neurological assessment scales. Parallel to the development of the guide, work meetings have been done monthly with administrative, in order to identify weak points of the circuit. These sessions served to specific training on nomenclature, identification of warning signs and correct processing and referral of patients.
introduction
Nursing Interventions Guide to Health Problems - Can Bou EAP
V 1.2 12/2012 Castelldefels Agents de Salut d’Atenció Primària CASAP 12
During the seven years we've been developing this project, the drive group, consisting of nurses, family physicians and administrative, has maintained regular work meetings, and have made the agreed modifications, both circuit and content according to a quality methodology. After closing the guide by the authors and agreed with contributors, there has been a review by three external professionals from three scientific entities: the Association of Family and Community Nursing of Catalunya (Aificc), the Catalan Society of Family and Communitary Medicine (Camfic) and Jordi Gol Foundation (Idiap)
Alba Brugués i Brugués
Nurse Attached to Direction-Management
Nursing Interventions Guide to Health Problems - Can Bou EAP
V 1.2 12/2012 Castelldefels Agents de Salut d’Atenció Primària CASAP 13
With the aim of giving the best service to the population served, the members of the Primary Care Team Can Bou pledge to continue the “nursing interventions guide to health problems” developed with the consensus of all team professionals. This Guide is based on current protocols and in the evidence recommended in our country by scientific societies and public health services entities.
With the same intention and willingness to offer a solving and efficient service, we agree to follow the circuits and procedures detailed in this compendium adapted for acute pathology attention and based on those documents. These circuits will be extended and procedures will be updated depending on the disposition of new scientific evidence and the degree of resolution of our Primary Care Team deems necessary.
Healthcare team of EAP Can Bou
Castelldefels, december de 2012
Nursing Interventions Guide to Health Problems - Can Bou EAP
V 1.2 12/2012 Castelldefels Agents de Salut d’Atenció Primària CASAP 15
p
Aggressions Cardiac arrest Seizures Heatstroke Severe abdominal pain Chest pain Fever >39ºC Intoxications Serious eye injury Intens headache Dizziness Drowning Loss of conscience Gastrointestinal
bleeding Traumatic brain injury Severe trauma Vomiting Anaphylactic shock

folds Sore throat Backache Toothache Discomfort when
urinating Animal bite Stye Bite Mosquito bite Allergic reaction Respiratory symptoms in
upper airways Sprained ankle Trauma Whitlows
2
portfolio
Clínic visit Drop Genital herpes & zoster Eye injuries: - Conjunctivitis - Slight lesions - Red eye
Otalgia Varicella Other acute health
problems non protocolized on 1, 3 i 4 group
RX Interpretation Administrative gestion Hospital discharges maternal IT IT with hospital report Recipes: - hospital report - > 72 h. delay
diary - morphics - antidepressants - benzodiazepines
1
Programming techniques on Diary Box: - Injection
Tracking cures Control BP Control OAT
(displaced)
Other acute health problems non protocolized on 3 & 4 groups
Pediatrician
Nursing Interventions Guide to Health Problems - Can Bou EAP
V 1.2 12/2012 Castelldefels Agents de Salut d’Atenció Primària CASAP 18
Date: 09/2007 Revision:: 08/2012 Version: 1.2
• Personal History • Drugs and allergies • Time of evolution • Clinical companion • Characteristics of pain • State vaccine (Td)
anamnesis
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• Vital Signs (Temp) • properties injury Oral thrush: • <7 days duration • One or few lesions smaller than 1cm. in diameter, whitish background and red outline • not have a high fever or malaise
assessment
• Analgesia if required as guideline: 1 gr/8h Paracetamol and /or Ibuprofen 600mg/8h • Topical Treatment: Carbenoxolone 2% gel 1 aplicación/8h. (6 days)
intervention
alert causes
• Other cases outside the oral cavity • At the discretion of the nurse
• If no improvement in 4-5 days
revisiting criteria
do ct
oral thrush
Nursing Interventions Guide to Health Problems - Can Bou EAP
V 1.2 12/2012 Castelldefels Agents de Salut d’Atenció Primària CASAP 19
NURSING INTERVENTIONS (NIC) INDISPENSABLE OPTIONAL 1400 Pain management 1710 Oral Health maintenance 2390 Medication prescribing 5616 Teaching: prescribed medication 5510 Health education 8100 Referral 7920 Documentation
NURSING DIAGNOSES NANDA 00132 Acute pain 00045 Impaired oral mucous membrane
oral thrush
Nursing Interventions Guide to Health Problems - Can Bou EAP
V 1.2 12/2012 Castelldefels Agents de Salut d’Atenció Primària CASAP 20
• Age • Personal history • Drugs and allergies • Time from intercourse (<72 h.) • Other unprotected intercourse in the same cycle • Clinical companion • Last rule • Regular contraceptive method • Known hypersensitivity • Intestinal malabsorption syndrome
anamnesis
re fe
• General condition • Pregnancy test if I delayed menstruation • Psychological and emotional maturity in girls 13-16 years
valoration
• 1500 mcg Levonorgestrel - Taken in front of us • Report: - If vomits before 2 h, must return to take another dose - If doesn’t have rule in 21 d. need to do a pregnancy test • Recommend a visit with ASSIR
intervention
• If time since intercourse> 72 h • If positive pregnancy test
• If a history of hypersensitivity to the drug • If intestinal malabsorption syndrome • Under 13 years old • If treatment with broad-spectrum antibiotics, antiepileptics, antifungals, antiretrovirals and/or tuberculostatic • At the discretion of the nurse
• If vomits before 2 h, must return to take another dose • If doesn’t have rule in 21 d. need to do a pregnancy test
revisiting criteria
nu rs
e
The "morning after pill" is an emergency contraception and can be used in unprotected sexual intercourse or suspected that the contraceptive method used may have failed.
emergency contraception
Nursing Interventions Guide to Health Problems - Can Bou EAP
V 1.2 12/2012 Castelldefels Agents de Salut d’Atenció Primària CASAP 21
NURSING DIAGNOSES NANDA 00188 Risk-prone health behavior 00126 Deficient knowledge: contraception and safe sex
NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 2300 Medication administration 5248 Sexual counseling 5510 Health education 5616 Teaching: prescribed medication 7920 Documentation 8100 Referral
emergency contraception
Nursing Interventions Guide to Health Problems - Can Bou EAP
V 1.2 12/2012 Castelldefels Agents de Salut d’Atenció Primària CASAP 22
Date: 09/2007 Revision: 08/2012 Version: 1.2
• Age • Causal agent • Personal history • Drugs and allergies • Time evolution • Clinical companion • Characteristics of pain • State vaccine (Td)
anamnesis
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• General condition • Vital Signs (temp and HR) • Grade, location, extension (see Annex 5) • Pain (see Annex 1) • Signs of infection • Presence of other lesions
valoration
• In all cases: - Assess the removal of clothing and objects - Wash and reduce local heat with physiological saline - Debride flictenas - Cures in wet environment with hydrocolloid with silver hydrofibre dressing or hydrophilic polyurethane gel or silver sulfadiazine - No compression elastic bandage - Tetanus prophylaxis if necessary • If pain: - Paracetamol 500 mg - 1 gr/6-8h. - Assess analgesia im d/p (if Metamizol im, telephone consultation)1 • If signs of infection: - Amoxi/clavulanate 500/125 mg c/8h. during 8 d. - If allergic to penicillin: Erythromycin 500 mg every/6 h during 8-10 d. • To tar: Dissolve with olive oil • Electrical burn: do ECG • Sunburn: - Moisturizer - Hydrocortisone Lotion 1%
intervention
alert causes
• Shock • Circulars and mucous • Skull, car, neck and genitals • Locations with significant aesthetic / functional compromise • 2nd grade> 10% body surface • 3rd grade> 2% body surface • power • inhalation • polytrauma • Suspected abuse or non-accidental origin • At the discretion of the nurse
• Signs of infection • Pain not controlled with scheduled analgesia • Reappearance of flictenas • Paresthesias • Signs of vascular compression • Malaise • Fever appearance • An incident occured with dressing
revisiting criteria
nu rs
e
It is the tissue injury caused by thermal, chemical, radioactive or physical contact that causes cell destruction, edema and fluid loss.
burn
Nursing Interventions Guide to Health Problems - Can Bou EAP
V 1.2 12/2012 Castelldefels Agents de Salut d’Atenció Primària CASAP 23
NURSING DIAGNOSES NANDA 00046 Impaired skin integrity 00044 Impaired tissue integrity 00132 Acute pain 00004 Risk for infection
NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 3660 Wound cure 2390 Medication prescribing 1400 Pain management 1380 Heat/Cold application 6530 Immunization/vaccines management 3584 Skin care: topical treatments 5510 Health education 2300 Medication administration 7920 Documentation 8100 Referral
burn
Nursing Interventions Guide to Health Problems - Can Bou EAP
V 1.2 12/2012 Castelldefels Agents de Salut d’Atenció Primària CASAP 24
• Age • Personal history • Drugs and allergies • Time evolution • Clinical companion • CVR factors • Mental health diagnoses • Psychological manifestations1 • Physical manifestations2
anamnesis
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or at
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• General condition • Vital signs (BP, HR, RR, SatO2) • Breathing type
valoration
• If oppressive chest pain: - Do ECG • If hyperventilation - Breaths with bag or mask - Tips and breathing exercises / relaxation3 • Diazepam 5 mg sbl./8h (give tt for 48h) • Report side effects • Preview / spontaneous appointment with referring doctor
intervention
alert causes
• ECG interpretation • Persistence of the clinic in 30' • If has already established a psychiatric treatment: telephone assessment • At the discretion of the nurse
• Exacerbation of symptoms
tension, tingling, dizziness, gastrointestinal disorders... 3 Deep diaphragmatic breathing: inspire slowly and deeply for 5'', hold the air during 5-7'’ and
exhale slowly during 10'' Relaxed diaphragmatic breathing: nose inspiration by 2-3'', pause briefly, exhale slowly for 4-6'' and do another short break before returning to inspire.
explanatory notes
do ct
or
Episode of sudden and unexpected occurrence that manifests itself with fear of losing control or that something bad must happen, or even fear of dying. It is accompanied by symptoms such as difficulty breathing, chest pain, palpitations, sweating, trembling, dizziness and unsteadiness, tingling, nausea, and abdominal discomfort.
anxiety attack
Nursing Interventions Guide to Health Problems - Can Bou EAP
V 1.2 12/2012 Castelldefels Agents de Salut d’Atenció Primària CASAP 25
NURSING DIAGNOSES NANDA 00146 Anxiety 00148 Fear 00032 Ineffective breathing pattern
NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 5820 Anxiety reduction 6160 Crisis intervention 6680 Vital signs monitoring 2300 Medication administration 3350 Respiratory monitoring 5230 Coping enhacement 5510 Health education 5880 Relaxation techniques 7920 Documentation 8100 Referral
anxiety attack
Nursing Interventions Guide to Health Problems - Can Bou EAP
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• Age • Personal history • Drugs and allergies • Time evolution • Clinical companion • Presence of vomiting • Stool characteristics (blood, pus or mucus) • Number and types of stools • Recent trips • Recent drugs • Others affected
anamnesis
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• General condition • Vital signs (temp, HR and BP) • Diabetic patient: capillary glycemia • Pain (see Annex 1) • Abdominal examination: soft belly and increased peristalsis • Hydration, skin and mucous
valoration
• Diet: - Oral Rehydration (water and infusions) - Dietary recommendations for the gradual reinstatement of food • Relative rest • If fever or pain: - Paracetamol 500 mg - 1gr/6-8h. o • If vomiting: - Metoclopramide 10 mg im /o • Hygiene standards • If necessary, provide IT (Telephone consultation. MF, N, print IT )
intervention
alert causes
• Important malaise • Fever> 38 ° C • immunosuppression • Fecal pathological products (blood, pus, mucus) • Duration of more than 3 days • Frequent vomiting> 5/12h or bloody • oral intolerance • Suspected food toxoinfección collective or pharmacological • DM with altered capillary glycemia • Signs of dehydration • Altered abdominal palpation • severe pain • Inflammatory bowel disease • Pain located at a point • At the discretion of the nurse
• If fever> 38 º C • Presence of blood, mucus and / or pus in stool • Onset of frequent vomiting (> 5/12h) • Persistence of…