The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [515]
Weber, J. and Kelley, J. (2003) Health Assessment in Nursing, 2nd edn. Lippincott Williams and Wilkins, Philadelphia.
Weldon, K. (1998) Neurological observations, in NeuroOncology for Nurses (ed. D. Guerrero). Whurr, London, pp. 1–28.
Weller, B (2005) Bailliére’s Nurses’ Dictionary for Nurses and Healthcare Workers, 24th edn. Elsevier, Edinburgh.
Wheatley, I. (2006) The nursing practice of taking level 1 patient observations. Intensive and Critical Care Nursing, 22, 115–121.
WHO (2006) Definition and Diagnosis of Diabetes Mellitus and Intermediate Hyperglycaemia. World Health Organization, Geneva. www.who.int/diabetes/publications/en/.
Wilkins, R.L. (2009) Bedside assessment of the patient, in Egan’s Fundamentals of Respiratory Care, 9th edn (eds R.L. Wilkins, J.K. Stoller and R.M. Kacmarek). Mosby Elsevier, St Louis, MO.
Williams, B., Poulter, N., Brown, M. et al. (2004) Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society 2004 – BHS IV. Journal of Human Hyptertension, 18 (3), 139–185.
Wilson, F., Johnson, F. and Rosenbaum, F. (1944) The precordial electrocardiogram. American Heart Journal, 27, 19–85.
Wilson, L.A. (2005) Urinalysis. Nursing Standard, 19 (35), 51–54.
Wong, F. (2007) Pulsus paradoxus in ventilated and nonventilated patients. Dynamics, 18 (3), 16–18.
Woodhall, L. (2008) Implementation of the SBAR communication technique in a tertiary centre. Journal of Emergency Nursing, 34 (4), 314–317.
Woodrow, P. (1999) Pulse oximetry. Nursing Standard, 13 (42), 42–46.
Woodrow, P. (2004a) Arterial blood pressure monitoring, in High Dependency Nursing Care: Observation, Intervention and Support (eds T. Moore and P. Woodrow). Routledge, London.
Woodrow, P. (2004b) Central venous pressure measurement and cardiac studies, in High Dependency Nursing Care: Observation, Intervention and Support (eds T. Moore and P. Woodrow). Routledge, London.
Woods, S., Froelicher, E.S., Motzer, S.A. et al. (2005) Cardiac Nursing, 5th edn. Lippincott Williams and Wilkins, Philadelphia.
Woollens, S. (1996) Temperature measurement devices. Professional Nurse, 11 (8), 541–547.
Zietz, K. and McCutcheon, H. (2006) Observations and vital signs: ritual or vital for the monitoring of postoperative patients? Applied Nursing Research, 19, 204–211.
Multiple choice questions
1 When should adult patients in acute hospital settings have observations taken?
a When they are admitted or initially assessed. A plan should be clearly documented which identifies which observations should be taken and how frequently subsequent observations should be done.
b When they are admitted and then once daily unless they deteriorate.
c As indicated by the doctor.
d Temperature should be taken daily, respirations at night, pulse and blood pressure 4 hourly.
2 Why are physiological scoring systems or early warning scoring systems used in clinical practice?
a They help the nursing staff to accurately predict patient dependency on a shiftbyshift basis.
b The system provides an early accurate predictor of deterioration by identifying physiological criteria that alert the nursing staff to a patient at risk.
c These scoring systems are carried out as part of a national audit so we know how sick patients are in the United Kingdom.
d They enable nurses to call for assistance from the outreach team or the doctors via an electronic communication system.
3 A patient on your ward complains that her heart is ‘racing’ and you find that the pulse is too fast to manually palpate. What would your actions be?
a Shout for help and run to collect the crash trolley.
b Ask the patient to calm down and check her most recent set of bloods and fluid balance.
c A full set of observations: blood pressure, respiratory rate, oxygen saturation and temperature. It is essential to perform a 12lead ECG. The patient should then be reviewed by the doctor.
d Check baseline observations and refer to the cardiology team.
4 When would