Download FoN Assignment exemplar feb 16 cohort - Moodle

School of Health Nursing & Midwifery - Assessment Title Page Template
Section 1: To be completed by the Module Co-ordinator prior to issuing to students
Module Code
NURS11078
Module Title
Foundation of Nursing
Assessment title
Essay
Assessment wordage (if applicable)
4500 (+10%)
Submission deadline (Date and Time)*
Date: 19/4/16
*The assessment must be submitted prior
to this deadline to avoid penalty
Time: 12 noon
(If the submission is via drop box, the time must
be 9am)
Section 2: To be completed by the student prior to submitting assessment
Word count
4,915
Originality Score (for final version of
27%
assignments submitted via Turnitin)
Banner ID number
B00300216
(this is an 8 digit number, preceded by the
letter ‘B’, eg B00123456)
Have you been granted a formal
NO
extension?
If yes:
Name of staff member who granted extension*:
Revised submission deadline for formal extension:
* Not all staff are permitted to grant extensions – please ensure any
extension is granted by a staff member approved to do so for this
module/assessment.
Section 3: To be completed by the student prior to submitting assessment
Is this a resubmission?
NO
How have you used previous assessment 1. N/A No previous feedback from UWS
feedback to help develop this assignment? 2.
3.
What 3 specific issues would you like
1. Content
assessment feedback on from this
2. Writing style / critical analysis
assignment?
3. Referencing
1
Module:
Foundations of Nursing (NURS11078)
Cohort:
MSc Adult Nursing February 2016
Submission Date:
19th April 2016
Word Count:
4,915
2
Contents
Introduction
4
Cluster 1: Care, Compassion and Communication
4
Urinary Catheter Management
Cluster 2: Organisational Aspects of Care
8
Respiration Monitoring
Cluster 5: Medicine Management
11
Administration of Medication via Subcutaneous and Intramuscular Injection
Conclusion
15
References
16
3
Introduction
The Nursing and Midwifery Council (NMC, 2010) state that all nurses must be responsible and
accountable for safe, compassionate, person-centred, evidence-based nursing. Nurses should
be mindful that health is multidimensional and a holistic approach should be employed,
encompassing biological and psychosocial factors alike (Hjelm, 2008). In 2007, the NMC
published the five Essential Skills Clusters (ESCs) as a direct response to a review, which
highlighted instances of nurses falling short of required standards at the point of registration
(Long, 2009a). The ESCs aim to clarify expectation for both the public and the nursing
profession and address skill deficits raised by the review (NMC, 2007a). The ESCs are
explicitly about promoting best practice and emphasising that all practice should be informed
by the best available evidence (Long, 2009b; NMC, 2010). The five ESCs are Care,
Compassion and Communication; Organisational Aspects of Care; Infection Prevention and
Control; Nutrition and Fluid Management; and Medicines Management. This assignment will
focus on one skill from three ESCs and critically analyse their application and development in
nursing practice, whilst demonstrating a critical understanding of the underpinning life and
social science theories. These skills will be considered in the context of delivering safe,
effective, person-centred care and the importance of effective communication during this
process. The skills which will be discussed are Urinary Catheter Management; Respiration
Monitoring; and Administration of Subcutaneous and Intramuscular Injections.
Cluster 1: Care, Compassion and Communication
Urinary Catheter Management
A catheter is a flexible tube which is inserted into narrow openings to enable fluids to be
introduced or removed (Martin, 2007). Urinary catheters are passed into the bladder either via
the urethra, urethral catheterisation; or via the anterior abdominal wall, which is commonly
referred to as suprapubic catheterisation (European Association of Urology Nurses (EAUN),
2012).
Urethral catheterisation can be classed as either intermittent or indwelling. Intermittent
catheterisation is the periodic insertion and immediate removal of a catheter (Newman and
Willson, 2011), whilst an indwelling catheterisation remains in-situ (National Institute for
Health and Care Excellence (NICE), 2012). According to NICE (2012), an indwelling catheter
4
which is in-situ for more than four weeks is classed as ‘long-term’. The Scottish Intercollegiate
Guidelines Network (SIGN) also classes a long-term catheter as being left in place for over 28
days, with a medium term catheter remaining for 7–28 days (SIGN, 2012).
Urethral catheters are passed for various reasons. These include acute and chronic urinary
retention; bypassing an obstruction; instilment of medications; monitoring renal function in
critically ill patients; enabling bladder function tests; management of intractable incontinence
(Royal College of Nursing (RCN), 2012; EAUN, 2012). There is, however, a consensus that
catheterisation as a long-term management solution of incontinence should only be considered
when all non-invasive options have been found to be inappropriate (NHS Quality Improvement
Scotland (NHS QIS), 2004; EAUN, 2012; NICE, 2012; RCN, 2012). Dougherty and Lister
(2015) go on to say that as placement of a urinary catheter is an invasive procedure the full
risks and benefits must be considered carefully beforehand.
Perhaps the most significant risk is infection. Indeed, according to Murphy, Fader and Prieto
(2014) indwelling urinary catheters are the cause of 80% of UTIs in acute care. Moreover, the
RCN (2012) explains that the risks associated with UTIs are becoming ever more serious due
to ever increasing rise of multi-resistant bacteria with associated life threatening complications.
The RCN (2012) clearly states that nurses involved in catheter care must have sound
knowledge of the causes of urinary tract invasion from bacteria and how to minimise such risk
in all care settings. NICE (2012) recommend that catheterisation should be an aseptic procedure
and indwelling catheters should be connected to a sterile closed urinary drainage system or
catheter valve. Richardson (2008) writes that it is of vital importance to maintain high levels
of personal hygiene in order to reduce the risk of catheter-associated urinary tract infections
(CAUTI). Nicol et al. (2012) describes that the removal of secretions and encrustations from
the meatus is the main aim of cleansing and that soap and water is entirely adequate for the
purpose. Indeed, a study by Willson et al., (2009) confirms this notion, discussing that the use
of ointments or antiseptic solutions during routine meatal care did not in fact reduce the
incidence of CAUTI. Both Nichol et al. (2012) and Richardson (2008) agree that daily
cleansing, as part of the patient’s normal hygiene routine, is sufficient to maintain meatal
hygiene. Kunin (1997) & Garibaldi (1998), cited in NHS QIS (2004), went as far to conclude
that risk of infection may actually be increased if frequent, vigorous meatal cleansing with
antiseptic solutions is employed.
5
Another notable problem is recurrent catheter blockage. Catheter blockage can occur in 4050% of patients (EAUN, 2012), as a result of a combination of encrustation and bacteria buildup (Davey, 2015). Blockage can often result in bypassing, leaking of urine or the discomfort
of urinary retention, which is often very distressing to both patients and carers (Getliffe, 2004).
Another important role of the nurse in catheter care, is to ensure that the patient takes regular
fluids, to help dilute the urine reducing the risk of encrustations and resulting blockages
(Davey, 2015; EAUN, 2012).
Urethral trauma and tissue inflammation are other issues associated with catheter use. Getliffe
(1995) discusses that this can be minimised by appropriate selection of catheter size and
material. Indeed, Richardson (2008) confirms that it is important for nurses to consider whether
the patient is allergic to latex and how long the catheter will be in situ when choosing material.
Dougherty and Lister (2015) have identified three broad timescales. For short term (1–7 days)
consider using Polyvinyl chloride (PVC). For short to medium term (up to 28 days) consider
using Teflon (polytetrafluoroethylene). For medium to long term (6–12 weeks) consider using
hydrogel and silicone coated catheters. NHS QIS (2004) and Dougherty and Lister (2015) both
agree that smaller catheters minimise urethral trauma and decrease the likelihood of patient
pain and discomfort. However, Richardson (2008) reminds us that a large diameter will provide
better drainage. Also, if debris or clots are present in the urine, then a larger gauge catheter will
be required (Dougherty and Lister, 2015).
Physical problems, such as CAUTI; catheter blockages; bypassing, should not be the limit of a
nurse’s focus when caring for a patient with a catheter. Indeed, the NHS QIS (2004) state that
psychological support and lifestyle issues must all be addressed. The RCN (2012) expand on
this notion, detailing that reviews of the impact of the catheter on lifestyle and quality of life
should include home life, employment, sexual activity, shopping, socialising, recreation and
sports, travel, staying away from home and holidays. The EAUN (2012) confirm that
psychological and social aspects of having an indwelling catheter have a profound influence
on the patient’s quality of life. Indeed, the social model of health provides a holistic definition
of health that acknowledges that in order for health and well-being to be achieved, social,
environmental and cultural factors must be addressed, alongside biological and medical factors.
(Barry and Yuill, 2012; Yuill, Crinson and Duncan, 2010).
Fowler et al. (2014, p.601) found that those who had difficulty adjusting to a long-term
indwelling catheter often described themselves as being socially isolated, with one participant
6
in the study explaining that she didn’t like socialising as she felt “unclean” as a result of a
catheter. For others, the unpredictability of catheter function led to anxiety and affected their
ability to socialise with confidence (Fowler et al., 2014; Wilde, 2002) However, on the other
hand, many people have described catheters giving them freedom from incontinence,
specifically freedom to leave the house for social activities or work (Prinijha & Chapple, 2014).
In Fowler et al’s. (2014) study, participants specifically mentioned having the freedom to attend
family events, such as a meal out, and attending such events were frequently viewed as a
measure of quality of life.
Chapple, Prinjha and Salisbury (2014) and Fowler et al. (2014) discuss the negative effect of
catheter use on body image and intimacy. Catheter use has been shown to affect sexual selfesteem and cause pain and discomfort during sexual intercourse (Chapple, Prinjha and
Salisbury, 2014). Wilde, Brasch and Zhang (2011) add, that a major source of embarrassment
is leaking urine during sex. However, the EAUN (2012) highlights that there is a lack of
research into how sexual intercourse is affected by catheter use. Chapple, Prinjha and Salisbury
(2014) also found that participants in their study felt that healthcare professionals could be
reluctant to discuss sex and sexuality. Indeed, for some people with a catheter, sex was not an
important part of their lives either due to old age or illness and disability (Chapple, Prinjha and
Salisbury, 2014) However, Roper, Logan and Tierney’s model of nursing lists expressing
sexuality as an activity of living (Holland, 2003). Therefore, patients with catheters require
support, open communication, and sensitivity from nurses (EAUN, 2012). Furthermore, if
nurses fail to bring up the subject of sex and sexuality, then patients with catheters will be in
the uncomfortable position of having to introduce the topic themselves (EAUN, 2012).
Living with a long-term indwelling catheter comes with many risks and benefits. Physical and
psychological support is a pivotal role of the nurse in helping users manage and adjust to life
with catheters (Fowler et al., 2014). Education is a key role of a nurse when caring for a patient
with a catheter. Indeed, the RCN (2012) emphasises that nurses must educate individuals in
maintaining catheter function, lifestyle, what to do in the event of problems with equipment,
reducing infection and how to deal with common complications. Patient consent and control
over their catheter is essential. Fowler et al. (2014) found that if patients were involved in the
decision to have a catheter inserted then levels of catheter acceptance as part of their daily lives
increased. Kralik et al. (2007) summarise the role and importance of the nurse in catheter care,
explaining that it the guidance from nurses in the early stages that can help patients with
7
catheters adjust and help improve their quality of life, health and reduce incapacity and social
isolation.
Cluster 2: Organisational Aspects of Care
Respiration Monitoring
The primary function of respiration is to supply oxygen to the cells of the body and remove
carbon dioxide (Quayle, 2008; Moore, 2007). Dougherty and Lister (2015) describe respiration
as being comprised of four processes: pulmonary ventilation; external respiration; transport of
respiratory gases; and internal respiration. Pulmonary ventilation is defined as the movement
of air in and out of the lungs and commonly referred to as breathing; external respiration is the
gaseous exchange which occurs between the lungs and the blood; transport of respiratory gases
refers to the movement of gases between the cells of the body and the lungs by the
cardiovascular system; and internal respiration is the movement of oxygen and carbon dioxide
between the blood and cells of the body. However, terminology and definitions vary. Indeed,
Hunter and Rawlings-Anderson (2008) describe respiration as having just three processes:
ventilation, diffusion and perfusion. Diffusion is used as an alternative label for external
respiration and perfusion an alternative for internal respiration. Moore (2007) explains that the
ventilation process is controlled through both voluntary and involuntary mechanisms. The
central nervous system regulates voluntary control of the muscles of respiration, which enables
conscious control over rate of breathing. The respiratory centre, comprising of the pons and the
medulla oblongata, controls the involuntary ventilation (Moore, 2007).
SIGN recommends that all adult patients in an acute hospital setting should have their
physiological observations recorded on admission and at least every 12 hours thereafter. Heart
rate; blood pressure; level of consciousness; oxygen saturation; temperature and respiratory
rate should be observed as a minimum (SIGN, 2014).
In addition to respiratory rate several other aspects of respiration should be considered. Indeed,
to ensure that a comprehensive respiratory assessment is undertaken and not the rate alone,
Hunter and Rawlings-Anderson (2008) recommend taking the ‘look, listen and feel’ approach.
The nurse will then be reminded to observe the patient, listen to the breathing and feel for chest
movement.
8
Before commencing any assessment consent should be obtained from the patient (Quayle,
2008; Nicol et al., 2012). However, there is a general consensus that it is advantageous not to
inform the patient you are specifically assessing their respiratory function, as this can often
lead to a subconscious response affecting respiration rate and rhythm (Quayle, 2008; Moore,
2007; Hunter and Rawlings-Anderson, 2008). Many nurses achieve this by assessing the
patient’s radial pulse, whilst simultaneously, observing the movement of the chest wall (Nicol
et al., 2012). The normal respiration rate for an adult is approximately 14 breaths per minute
(Cox and Roper, 2005), with a normal range of 12-18 breaths per minute (Higginson and Jones,
2009). However, Cox and Roper (2005) discuss that there is disagreement over the normal rate
with some suggesting that normal rate averages at 20 breaths per minute with a normal range
of 16-25 breaths per minute. This lack of clarity has led to variations in the definitions of
abnormal. For example, Devereux and Douglas (2005) state that a rate > 15 breaths per minute
should be classed as tachypnoea, whilst Hunter and Rawlings-Anderson (2008) defines
tachypnoea as > 20 breaths per minute.
In addition to rate; rhythm, movement, depth and degree of effort should all be considered
(Dougherty and Lister, 2015; Higginson and Jones, 2009) The normal respiratory rhythm
should present as regular cycles, with the inspiratory phase being slightly shorter that the
expiratory phase (Moore, 2007). Ahern and Philpot (2002) discuss that chest movement should
be equal, bilateral and symmetrical. Asymmetrical expansion of the chest is abnormal and can
be caused by any form of unilateral lung or pleural disease (Higginson and Jones, 2009). The
depth of breathing should be described using the terms shallow, normal or deep (Hunter and
Rawlings-Anderson, 2008). In addition, it is important to note the effort required by the patient
to breathe. Normal breathing should be effortless and quiet. If the patient is using accessory
muscles, such as the sternocleidomastoid, then breathing is said to be laboured (Moore, 2007;
Hunter and Rawlings-Anderson, 2008).
Changes to skin colour and breathing noises should also be acknowledged and recorded
(Hunter and Rawlings-Anderson, 2008). Cyanosis is the bluish discolouration of the skin and
mucous membranes and is a useful indication of levels of haemoglobin saturation (Higginson
and Jones, 2009). However, Moore (2007) warns that cyanosis if often difficult to appreciate
in artificial lighting and can be easily overlooked. She comments that it is most commonly
detected on and around the lips and under the tongue. Nicol et al. (2012) and Quayle (2008)
also discuss the importance of listening during a respiratory assessment. Wheezing, grunting,
stridor, snoring, sighing and gasping can all be signs of respiratory distress.
9
A change in respiratory status may also be attributed to psychological status. Wilhelm, Gevirtz
and Roth (2001, p. 513) describe respiration as “a physiological function situated strategically
at the interface of mind and body”. Indeed, a common cause of tachypnoea is anxiety (Gray
and Robertson, 2005; Moore, 2007). Tachypnoea may then escalate sufficiently to result in
hyperventilation. Martin (2007) defines hyperventilation as a reduced carbon dioxide
concentration of arterial blood as a consequence of breathing at an abnormally rapid rate at
rest. This leads to dizziness, tingling in the lips and limbs and cramping of hands and across
the chest and if persists, hyperventilation may result in loss of consciousness (Martin, 2007).
Acute anxiety and emotional distress are common triggers of hyperventilation (Devereux and
Douglas, 2005; Wilhelm, Gevirtz and Roth, 2001). It is therefore important that nursing staff
ensure a holistic, patient-approach to assessment and management, in order to identify and
action such psychological issues which may affect physiological observations (Dougherty and
Lister, 2015).
NICE (2007) recommend that a physiological track and trigger system, such as the Early
Warning Score (EWS), be employed with all adult patients in the acute hospital setting, to
allow for an appropriate response by the multidisciplinary team (MDT). If a patient’s vital signs
are of cause for concern, it is crucial that information relating to the patient’s deterioration is
communicated in a clear and precise manner to the MDT (Steen, 2010). A number of
communication tools are available, however many hospitals now use the SBAR (situation,
background, assessment, recommendation) tool (Nicol et al., 2012).
When monitoring a patient’s vital signs, the obvious rationale for including respiratory function
is to determine the respiratory status of a patient (Hunter and Rawlings-Anderson, 2008).
However, Cretikos et al. (2008) argue that that the respiratory status, and more specifically
rate, is an important indicator of derangement of many body systems, not just the respiratory
system, and indeed is a key predictor of a patient’s deterioration. Evidence from a study
conducted by Fieselmann et al. (1993) supports this notion. They found that a respiratory rate
higher than 27 breaths per minute was an important predictor of a cardiac arrest. Furthermore,
Goldhill et al. (2005) found that patients with a respiratory rate of 25-29 breaths per minute
had a 21% mortality rate. Of all the vital signs, Subbe et al. (2003) contend that respiratory rate
is the most valuable when predicting sudden illness in a patient. They found that changes in
blood pressure and pulse rate were comparatively small in relation to changes in respiratory
rate prior to deterioration and therefore more significant when discriminating between stable
patients and those at risk.
10
Despite all these findings, the evidence suggests that respiratory rate is not routinely being
recorded as part of observation of vital signs. Indeed, the National Confidential Enquiry into
Patient Outcome and Death concluded that pulse, blood pressure and temperature were most
frequently recorded, whilst respiratory rate was the least recorded variable (Cullinane et al.,
2005). Hogan (2006) supports this, concluding that respiratory rate was recorded, by nursing
staff, less than 50% of the time. Parkes (2011) found that nurses did not document respiratory
rate routinely, except for patients who presented with itching, seizure or shortness of breath or
with complaints caused by chemical exposure.
One reason which may explain this finding is the introduction of the pulse oximeter in
hospitals. It was found that its purpose and correct use was poorly understood amongst nurses,
with only 56% understanding that pulse oximetry is not an indicator of adequate ventilation
(Attin et al., 2002; Bilgin et al, 2000). Hogan (2006) also found that nurses were often unaware
of the functional limitations of such electronic equipment and that generally, nurses now place
a great reliance on electronic equipment to assist with patient monitoring. However, Ansell,
Meyer and Thompson (2014) add to the debate, citing other reasons for nurses failing to
routinely monitor respiration rate, namely time pressures; work interruptions; and rationalised
judgements made by experienced nurses. Nevertheless, as a result of failure to monitor, record
and interpret vital signs, SIGN (2014) has stipulated that observations should only be
performed by suitably trained staff who understand their clinical relevance. Ongoing education
and regular assessment of staff involved in these procedures is also crucial (SIGN, 2014).
Cluster 5: Medicine Management
Administration of Medication via Subcutaneous and Intramuscular Injection
Every year, according to the World Health Organisation (WHO), at least 16 billion injections
are administered globally, making injections one of the most common healthcare procedures.
90% of these injections are given for curative purposes, with immunisation injections
accounting for only 5% (WHO, 2015). As a nurse, administering medication via injection is a
common skill widely used in clinical practice, and requires understanding of the guiding
principles that underpin this clinical skill (Hunter, 2008b). These principles include anatomy,
physiology, pharmacology, patient assessment, preparation and technique (Hunter, 2008b;
Ogston-Tuck, 2014). The Nursing and Midwifery Council (NMC) recommends that all aspects
of this skill should be evidence-based to guarantee that nurses provide safe and accountable
11
practice (NMC, 2007b). However, Ogston-Tuck (2014) suggests that nurses’ practice may not
exclusively be evidence-based and instead, nurses often use technique that is familiar or
comfortable.
Dougherty and Lister (2015) list eight different types of injections: intradermal; subcutaneous
(SC); intramuscular (IM); intra‐arterial; intraosseous; intra‐articular; intrathecal; and
intravenous. This essay will focus on two, namely SC injection and IM injection. When
considering any administration of medicine, patient safety is of paramount importance (NMC,
2007b; National Patient Safety Agency (NPSA), 2009). In 2007 alone, the NPSA cites over
70,000 medication incident reports which resulted in 100 associated deaths. 62% of all
medicine incidents which resulted in severe harm or death, involved injectable medicines
(NPSA, 2009). As a result of such safety issues, the Department of Health (DoH) published
recommendations for the safer administration of medications, which include guidelines often
referred to as the 5Rs. Before administering a medication, the guidelines encourage healthcare
professionals to consider: Right Patient; the Right Drug; the Right Dose; the Right Route and
the Right Time. (DoH, 2004).
SC injection technique refers to the injection of medication beneath the epidermis into the
adipose or fatty tissue and connective tissue underlying the dermis (Hunter, 2008b). This type
of injection is used to deliver small doses of non-irritating, water soluble substances, such as
heparin and insulin (Downie, MacKenzie and Williams, 2003). IM injections, on the other
hand, deposit medication into deep muscle tissue, beyond the subcutaneous tissue (Cummings,
2008). It is important to choose the correct route as absorption rates vary greatly depending on
the route of injection. Indeed, Hunter (2008b) explains that the SC route is chosen when slow
continuous absorption of the medication is required. Whilst, via the IM route, a well-perfused
muscle will provide rapid absorption of medication (Cummings, 2008), and in relatively large
doses of up to 5 millimetres (Campbell, 1995). Most vaccines should be delivered
intramuscularly, to optimise the vaccine’s immunogenicity and reduce the risk of adverse
reactions at the injection site (Zuckerman, 2000). Other examples of drugs injected
intramuscularly are analgesics, anti-emetics, sedatives and hormonal treatments (Hunter,
2008a).
The site of injection is an important consideration for both SC and IM injections (Ogston-Tuck,
2014). Nicoll and Hesby (2002) add to this, stating that site selection is the single most
consistent factor associated with injury and complications. The most common sites for SC
12
injections are the lateral aspects of the upper arms and thighs and the umbilical region of the
abdomen (Hunter, 2008b). Lister and Sarpel (2004) explain that the upper arms are a preferred
choice as the arms have fewer large blood vessels and lower levels of pain sensations, which
reduces patient discomfort. Also significant when administering SC drugs, is that the amount
of subcutaneous tissue has been found to vary more than previously thought (Dougherty and
Lister, 2015). So, for example, if insulin is delivered inadvertently via the IM route, increased
absorption rate can lead to unexpected hypoglycaemia (King, 2003). The nurse should also
consider whether the patient is receiving regular SC injections, and if so should rotate the site
to avoid irritation, scarring, hardening of the tissue and pain (Hunter, 2008b).
The main sites that may be utilised for IM injections are the deltoid muscle of the upper arm;
the ventrogluteal site; the upper outer quadrant of the dorsogluteal; and two sites in the thigh,
namely the rectus femoris; and the vastus lateralis (Nicol et al., 2012; Rodger and King, 2000).
There is some debate over which is the best site to use (Dougherty and Lister, 2015) but current
evidence states that the vastus lateralis and the ventrogluteal should be used (Nisbet, 2006;
Cocoman and Murray, 2010). Indeed, Greenway (2004) advocates use of the ventrogluteal site
as it is free from major blood vessels and nerves, and the subcutaneous fatty tissue is of
consistent thinness. However, it has been found that nurses in the UK tend to use the
dorsogluteal site when administering IM injections due to familiarity with the site and lack of
confidence with others (Greenway, 2004). Supporting this, Walsh and Brophy (2010) found in
their study that 71% primarily used this site, despite evidence-based research recommending
otherwise.
There is some disagreement as to whether the skin should be cleaned prior to an injection.
Hunter, (2008b) and Nicol et al., (2012) argue that skin should not be cleaned as the repeated
use of alcohol will harden skin over time. Also, if the injection is given before the skin is dry,
Hunter (2008a) contends that, the cleansing procedure is ineffective and pain and stinging from
the antiseptic may be experienced by the patient. As a result of this evidence-based research
some local policies no longer recommend skin cleansing if the patient’s skin is not visibly dirty
(Hunter, 2008a, Nicol et al., 2012).
Traditionally, SC injections have been administered using a 45° angle (Hunter, 2008b).
However, since the introduction of shorter needles, the 45° angle has been challenged and new
evidence recommends SC injections should be administered at 90° to ensure medication is
deposited in the SC layer (King, 2003; Cummings, 2008). IM injections should be administered
13
at a 90° angle (Cummings, 2008; Nicol et al., 2012; Dougherty and Lister, 2015). For this IM
route of injection, Hunter (2008a) and Nicol et al. (2012) recommend using a green, 21-gauge
needle for all adults to ensure that the medication is delivered into the muscle. However, several
studies suggest that a notable percentage of IM injections are being deposited subcutaneously
in error due to increasing levels of obesity among the general population (Chan, 2006; Nisbet,
2006; Zaybak et al., 2007). Nisbet (2006) found that due to the depth of fat, IM injections into
the posterior gluteal site were delivered subcutaneously in 43% of patients in his study.
When administering a SC injection, it is recommended to pinch the skin to lift the adipose
tissue from the underlying muscle, to prevent administering an IM injection in error (Nicol et
al., 2012; King, 2003; Forum for Injection Technique, 2011). In contrast, when administering
IM injections, the skin is flattened and stretched over the injection site (Hunter, 2008a; Nicol
etal., 2012), the rationale being, to displace the underlying SC tissue and aid the insertion of
the needle (Hunter, 2008a). However, Pullen (2005) contends that the Z-track method should
be used for all IM injections in adults. By temporarily moving and returning the skin and
subcutaneous tissue, the zig-zag path created seals the needle tract. It is argued that this
technique prevents medication leaking into the SC tissue, minimises skin lesions and irritation
and may also be less painful (Dougherty and Lister, 2015; Pullen, 2005).
The general consensus is that it is not necessary to aspirate after insertion of the needle in SC
injections, as it is rare for a blood vessel to be pierced (Nicol et al., 2012; Peragallo-Dittko,
1997 cited in Cummings, 2008). In contrast, it is recommended that when administering an IM
injection, the plunger of the syringe is withdrawn slightly once in situ, to confirm the needle is
in the correct position and not in a blood vessel (Hunter, 2008a; Nicol etal., 2012). However,
it is argued that aspiration has become merely custom in the IM procedure and is unnecessary,
as nurses should be confident in their knowledge of anatomy and needle placement (Sisson,
2015).
Excellent communication is an important nursing skill when administering an injection (NMC,
2015). Alongside gaining the patient’s consent (NMC, 2015), an IM or SC injection procedure
should be fully explained to the patient (Nicol et al., 2012). Dougherty and Lister (2015) also
cite the importance of listening to the views and advice of an experienced patient. The preprocedural discussion should include site choice and allow for concerns or anxieties regarding
the procedure to be addressed (Hunter, 2008b; Ogston-Tuck, 2014). Indeed, this is important,
as pain and associated anxieties are commonplace amongst patient’s receiving injections
14
(Alavi, 2007; Barnhill, 2006; Chung, Ng and Wong, 2002). Mohr, Cox and Merluzzi (2005)
found that at least 3.5% of Americans have an injection phobia, which is so severe that it
prevents them from receiving further injections and 22% have a milder phobia resulting in
anxiety when being injected. Anxiety and fear have also been found to magnify pain (Chamley,
2011). Nurses, therefore, must communicate effectively with patients, with compassion and
politeness, in order to deliver individualized safe-care and treatment, and appropriately manage
psychological concerns surrounding injections (Dougherty and Lister, 2015; NMC, 2015).
Conclusion
The WHO (2003) states that the nurse’s role involves helping patients, families and groups to
define and achieve their physical, mental and social potential, and within the context of the
environment in which they work and live. Nurses provide professional assessment and care
during illness and rehabilitation, which encompasses the physical, mental and social aspects of
life, as all these aspects affect illness, health, disability and dying (WHO, 2003). In order to
achieve this holistic, multi-dimensional approach to healthcare, it is essential that the patient is
at the centre of their care and involved throughout the process (NMC, 2010). Nurses must aim
to achieve patient autonomy, and independence should be promoted in every aspect of daily
living (Roper, Logan & Tierney, 2001; NMC, 2010). The NMC (2015) also emphasise the need
for effective and safe practise. In order to achieve this, it is recommended that a nurse’s
knowledge and skills are kept up-to-date and evidenced-based (NMC, 2015; WHO, 2003).
Professional, evidence-based standards such as the ESCs set the standards for nurses’ education
and training and are fundamental to best practice (Long, 2009b). A nurse must communicate
clearly and maintain effective communication with the MDT and the patient. This includes
gaining informed patient consent prior to any action, having communicated all risks, benefits
and alternatives (NMC, 2015).
15
References
Ahern, J. and Philpot, P. (2002) Assessing acutely ill patients on general wards. Nursing
Standard. [Online] Vol.16 (47), pp.47–53. Available:
http://search.proquest.com/docview/219818380/fulltextPDF/BAF8F6FA51354329PQ/1?acco
untid=13056 [Accessed 5 Mar 2016].
Alavi, N. M. (2007) Effectiveness of acupressure to reduce pain in intramuscular
injections. Acute Pain. [Online] Vol.9 (4), pp.201–205. Available: Elsevier [Accessed 21 Mar
2016].
Ansell, H., Meyer, A. and Thompson, S. (2014) Why don’t nurses consistently take patient
respiratory rates? British Journal of Nursing. [Online] Vol.23 (8), pp.414–418. Available:
magonlinelibrary.com [Accessed 26 Mar 2016].
Attin, M., Cardin, S., Dee, V., Doering, L., Dunn, D., Ellstrom, K., Erickson, V., Etchepare,
M., Gawlinski, A., Haley, T., Henneman, E., Keckeisen, M., Malmet, M. and Olson, L.
(2002) An educational project to improve knowledge related to pulse Oximetry. American
Journal of Critical Care. [Online] Vol.11 (6), pp.529–534. Available:
http://ajcc.aacnjournals.org/content/11/6/529.long [Accessed 6 Mar 2016].
Barnhill, B. J., Holbert, M. D., Jackson, N. M. and Erickson, R. S. (1996) Using pressure to
decrease the pain of intramuscular injections. Journal of Pain and Symptom Management.
[Online] Vol.12 (1), pp.52–58. Available: http://www.jpsmjournal.com/article/08853924(96)00049-8/pdf [Accessed 21 Mar 2016].
Barry, A.-M. and Yuill, C. (2012) Understanding the sociology of health. 3rd ed. London:
SAGE Publications.
Bilgin, H., Kutlay, O., Cevheroglu, D. and Korfali, G. (2000) Knowledge about pulse
oximetry among residents and nurses. European Journal of Anaesthesiology. [Online] Vol.17
(10), pp.650–651. Available:
http://web.b.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=f511ea1e-958e-4d3b-9abc631c6381ce51%40sessionmgr115&vid=1&hid=118 [Accessed 1 Mar 2016].
Campbell, J. (1995) Injections. Professional Nurse. Vol.10 (7), pp.455–458.
Chan, V. O., Colville, J., Persaud, T., Buckley, O., Hamilton, S. and Torreggiani, W. C.
(2006) Intramuscular injections into the buttocks: Are they truly intramuscular? European
16
Journal of Radiology. [Online] Vol.58 (3), pp.480–484. Available: http://ac.elscdn.com/S0720048X06000349/1-s2.0-S0720048X06000349-main.pdf?_tid=2523e3a4-ef8011e5-9ca4-00000aacb361&acdnat=1458577116_ea1f42ce24c995a82b745e217dd43291
[Accessed 21 Mar 2016].
Chapple, A., Prinjha, S. and Salisbury, H. (2014) How users of indwelling urinary catheters
talk about sex and sexuality: A qualitative study. British Journal of General Practice. [Online]
Vol.64 (623), pp. e364–e371. Available: http://bjgp.org/content/bjgp/64/623/e364.full.pdf
[Accessed 16 Feb 2016].
Chamley, C. (2011) Pain management. In: Brooker, C. and Nicol, M. (eds.). Alexander’s
nursing practice. Edinburgh: Churchill Livingstone/Elsevier, pp.551–574.
Chung, J. W. Y., Ng, W. M. Y. and Wong, T. K. S. (2002) An experimental study on the use
of manual pressure to reduce pain in intramuscular injections. Journal of Clinical Nursing.
[Online] Vol.11 (4), pp.457–461. Available: Wiley [Accessed 21 Mar 2016].
Cocoman, A. and Murray, J. (2010) Recognizing the evidence and changing practice on
injection sites. British Journal of Nursing. [Online] Vol.19 (18), pp.1170–1174. Available:
https://www.researchgate.net/publication/47429966_Recognizing_the_evidence_and_changi
ng_practice_on_injection_sites [Accessed 21 Mar 2016].
Cox, N. and Roper, T. A., eds. (2005) Clinical skills. Oxford: Oxford University Press.
Cretikos, M., Bellomo, R., Hillman, K., Chen, J., Finfer, S. and Flabouris, A. (2008)
Respiratory rate: the neglected vital sign. Medical Journal of Australia. [Online] Vol.188
(11), pp.657–659. Available:
https://www.mja.com.au/system/files/issues/188_11_020608/cre11027_fm.pdf [Accessed 26
Mar 2016].
Cullinane, M., Findlay, G., Hargraves, C. and Lucas, S. (2005) An acute problem? [Online].
London: National Confidential Enquiry into Patient Outcome and Death. Available:
http://www.ncepod.org.uk/2005report/ [Accessed 6 Mar 2016].
Cummings, J. (2008) The administration of medicines. In: Richardson, R. (ed.). Clinical
skills for student nurses: Theory, practice, and reflection. Exeter: Reflect Press, pp.284–327.
Davey, G. (2015) Troubleshooting indwelling catheter problems in the community. Journal of
Community Nursing. [Online] Vol.29 (4), pp.67–74. Available:
17
http://web.a.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=5fd3deef-c3af-41ee-bbea4d8f179a332b%40sessionmgr4002&vid=1&hid=4104 [Accessed 29 Feb 2016].
Department of Health (2004) Building a safer NHS for patients. Improving medication
safety. [Online]. Available:
http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_cons
um_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4084961.pdf [Accessed
17 Mar 2016].
Devereux, G. and Douglas, G. (2005) The respiratory system. In: Douglas, G., Nicol, F., and
Robertson, C. (eds.). Macleod’s clinical examination. Edinburgh: Elsevier Churchill
Livingstone, pp.123–152.
Dougherty, L. and Lister, S., eds. (2015) The royal marsden hospital manual of clinical
nursing procedures [Online]. 9th ed. Oxford: Wiley-Blackwell. Available:
http://www.rmmonline.co.uk.oalaproxy.uws.ac.uk/ [Accessed 16 Feb 2016].
Downie, G., MacKenzie, J. and Williams, A. (2003) Oral, parenteral and transdermal
administration of medicines. In: Downie, G., MacKenzie, J., and Williams, A.
(eds.). Pharmacology and medicines management for nurses. Edinburgh: Churchill
Livingstone, pp.67–89.
Erickson, V., Cardin, S., Dee, V., Doering, L., Dunn, D., Ellstrom, K., Attin, M., Etchepare,
M., Gawlinski, A., Haley, T., Henneman, E., Keckeisen, M., Malmet, M., Olson, L., Angeles,
L., Center, M. and Calif (2002) An educational project to improve knowledge related to pulse
Oximetry. American Journal of Critical Care. [Online] Vol.11 (6), pp.529–534. Available:
http://ajcc.aacnjournals.org/content/11/6/529.long [Accessed 6 Mar 2016].
European Association of Urology Nurses (2012) Catheterisation. Indwelling catheters in
adults [Online]. Available: http://www.nursing.nl/PageFiles/11870/001_1391694991387.pdf
[Accessed 29 Feb 2016].
Fieselmann, J. F., Hendryx, M. S., Helms, C. M. and Wakefield, D. S. (1993) Respiratory
rate predicts cardiopulmonary arrest for internal medicine inpatients. Journal of General
Internal Medicine. [Online] Vol.8 (7), pp.354–360. Available:
http://link.springer.com/article/10.1007/BF02600071 [Accessed 6 Mar 2016].
18
Forum for Injection Technique (2011) The first UK injection technique recommendations
2nd edition [Online]. Available:
http://fit4diabetes.com/files/2613/3102/3031/FIT_Recommendations_Document.pdf
[Accessed 21 Mar 2016].
Fowler, S., Godfrey, H., Fader, M., Timoney, A. G. and Long, A. (2014) Living with a longterm, indwelling urinary catheter. Journal of Wound, Ostomy and Continence Nursing.
Vol.41 (6), pp.597–603.
Getliffe, K. (1995) Long-term catheter use in the community. Nursing Standard. Vol.9 (31),
pp.25–27.
Getliffe, K. (2004) The effect of acidic maintenance solutions on catheter longevity. Nursing
times. Vol.100 (16), pp.32–4.
Goldhill, D. R., McNarry, A. F., Mandersloot, G. and McGinley, A. (2005) A
physiologically-based early warning score for ward patients: The association between score
and outcome. Anaesthesia. [Online] Vol.60 (6), pp.547–553. Available:
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.2005.04186.x/epdf [Accessed 6 Mar
2016].
Gray, A. and Robertson, C. (2005) The critically ill patient. In: Douglas, G., Nicol, F., and
Robertson, C. (eds.). Macleod’s clinical examination. Edinburgh: Elsevier Churchill
Livingstone, pp.381–395.
Greenway, K. (2004) Using the ventrogluteal site for intramuscular injection. Nursing
Standard. [Online] Vol.18 (25), pp.39–42. Available: ProQuest Health [Accessed 21 Mar
2016].
Higginson, R. and Jones, B. (2009) Respiratory assessment in critically ill patients: Airway
and breathing. British Journal of Nursing. [Online] Vol.18 (8), pp.456–461. Available:
http://web.a.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=6b31923d-3306-4e90-8fb5f4b5f137ce87%40sessionmgr4005&vid=1&hid=4104 [Accessed 5 Mar 2016].
Hjelm, J. R. (2008) The dimensions of health: Conceptual models. Sudbury, MA: Jones and
Bartlett Publishers.
Hogan, J. (2006) Why don’t nurses monitor the respiratory rates of patients? British Journal
of Nursing. [Online] Vol.15 (9), pp.489–492. Available:
19
http://web.b.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=315b80fc-5d59-4f57-9388ed672259bd34%40sessionmgr115&vid=1&hid=118 [Accessed 1 Mar 2016].
Holland, K. (2003) An introduction to the Roper-Logan-Tierney model for nursing, based on
activities of living. In: Holland, K., Jenkins, J., Solomon, J., and Whittam, S. (eds.). Applying
the Roper-Logan-Tierney model in practice. Edinburgh: Churchill Livingstone, pp.3–22.
Hunter, J. (2008a) Intramuscular injection techniques. Nursing Standard. [Online] Vol.22
(24), pp.35–40. Available: ProQuest Health [Accessed 21 Mar 2016].
Hunter, J. (2008b) Subcutaneous injection technique. Nursing Standard. [Online] Vol.22 (21),
pp.41–44. Available: ProQuest [Accessed 17 Mar 2016].
Hunter, J. and Rawlings-Anderson, K. (2008) Respiratory assessment. Nursing Standard.
[Online] Vol.22 (41), pp.41–43. Available:
http://search.proquest.com/docview/219840447/fulltextPDF/3B672DDC79114B1CPQ/3?acc
ountid=13056 [Accessed 1 Mar 2016].
King, L. (2003) Subcutaneous insulin injection technique. Nursing Standard. [Online] Vol.17
(34), pp.45–52. Available: ProQuest Health [Accessed 21 Mar 2016].
Kralik, D., Seymour, L., Eastwood, S. and Koch, T. (2007) Managing the self: Living with an
indwelling urinary catheter. Journal of Clinical Nursing. [Online] Vol.16 (7b), pp.177–185.
Available: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2702.2005.01440.x/pdf
[Accessed 16 Feb 2016].
Lister, S. and Sarpal, N. (2004) Drug administration: general principles. In: Dougherty, L.
and Lister, S. (eds.). The royal marsden hospital manual of clinical nursing procedures.
Oxford: Blackwell, pp.184–227.
Long, G. (2009a) Foreword. In: Childs, L., Coles, L., and Marjoram, B. (eds.). Essential
skills clusters for nurses: Theory for practice. Ames, IA: Wiley-Blackwell (an imprint of John
Wiley & Sons Ltd), pp. vii–viii.
Long, G. (2009b) A yardstick for good practice. Nursing Standard. [Online] Vol.23 (50),
pp.62–63. Available: ProQuest [Accessed 22 Mar 2016].
Martin, E., ed. (2007) Oxford concise colour medical dictionary. 4th ed. Oxford: Oxford
University Press.
20
Mohr, D. C., Cox, D. and Merluzzi, N. (2005) Self-injection anxiety training: A treatment for
patients unable to self-inject injectable medications. Multiple Sclerosis. [Online] Vol.11 (2),
pp.182–185. Available: Sage Publications [Accessed 21 Mar 2016].
Moore, T. (2007) Respiratory assessment in adults. Nursing Standard. [Online] Vol.21 (49),
pp.48–58. Available:
http://search.proquest.com/docview/219829899/fulltextPDF/4FE3A2A01B8446CDPQ/1?acc
ountid=13056 [Accessed 1 Mar 2016].
Murphy, C., Fader, M. and Prieto, J. (2014) Interventions to minimise the initial use of
indwelling urinary catheters in acute care: A systematic review. International Journal of
Nursing Studies. [Online] Vol.51 (1), pp.4–13. Available:
http://www.journalofnursingstudies.com/article/S0020-7489(12)00435-X/pdf [Accessed 29
Feb 2016].
NHS Quality Improvement Scotland (2004) Urinary catheterisation and catheter. Best
practice statement [Online]. Available:
http://www.healthcareimprovementscotland.org/idoc.ashx?docid=feaef66c-08e3-4168-ae5c85eba638ae8b&version=-1 [Accessed 29 Feb 2016].
National Institute for Health and Care Excellence (2007) Acute illness in adults in hospital:
recognising and responding to deterioration[Online]. Available:
https://www.nice.org.uk/guidance/cg50 [Accessed 22 Mar 2016].
National Institute for Health and Care Excellence (2012) Healthcare-associated infections:
Prevention and control in primary and community care [Online]. Available:
https://www.nice.org.uk/guidance/cg139 [Accessed 29 Feb 2016].
National Patient Safety Agency (2009) Safety in doses improving the use of medicines in the
NHS learning from national reporting 2007[Online]. Available:
http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=61626&type=full&servi
cetype=Attachment [Accessed 17 Mar 2016].
Newman, D. and Willson, M. (2011) Review of intermittent catheterization and current best
practices. Urologic nursing. [Online] Vol.31 (1), pp.12–28. Available:
http://web.a.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=1da1062d-8a96-414c-9f46adcb45785726%40sessionmgr4003&vid=2&hid=4104 [Accessed 29 Feb 2016].
21
Nicol, M., Bavin, C., Cronin, P., Rawlings-Anderson, K., Cole, E. and Hunter, J.
(2012) Essential nursing skills: Clinical skills for caring. 4th ed. Edinburgh: Elsevier.
Nicoll, L. H. and Hesby, A. (2002) Intramuscular injection: An integrative research review
and guideline for evidence-based practice. Applied Nursing Research. [Online] Vol.15 (3),
pp.149–162. Available: Science Direct [Accessed 15 Apr 2016].
Nisbet, A. C. (2006) Intramuscular gluteal injections in the increasingly obese population:
Retrospective study. British Medical Journal. [Online] Vol.332 (7542), pp.637–638.
Available: http://www.bmj.com/content/bmj/332/7542/637.full.pdf [Accessed 21 Mar 2016].
Nursing and Midwifery Council (2007a) Introduction of essential skills clusters for preregistration nursing programmes [Online]. Available:
https://www.nmc.org.uk/globalassets/sitedocuments/circulars/2007circulars/nmccircular07_2
007.pdf [Accessed 22 Mar 2016].
Nursing and Midwifery Council (2007b) Standards for medicines management record
keeping guidance for nurses and midwives[Online]. Available:
https://www.nmc.org.uk/globalassets/sitedocuments/standards/nmc-standards-for-medicinesmanagement.pdf [Accessed 18 Mar 2016].
Nursing and Midwifery Council (2010) Standards for Pre-registration nursing
education [Online]. Available:
https://www.nmc.org.uk/globalassets/sitedocuments/standards/nmc-standards-for-preregistration-nursing-education.pdf [Accessed 22 Mar 2016].
Nursing and Midwifery Council (2015) The code. Professional standards of practice and
behaviour for nurses and midwives[Online]. Available:
https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf
[Accessed 21 Mar 2016].
Ogston-Tuck, S. (2014) Subcutaneous injection technique: An evidence-based
approach. Nursing Standard. [Online] Vol.29 (3), pp.53–58. Available: RCNi [Accessed 17
Mar 2016].
Parkes, R. (2011) Rate of respiration: The forgotten vital sign. Emergency Nurse. [Online]
Vol.19 (2), pp.12–17. Available:
22
http://search.proquest.com/docview/868670744/fulltextPDF/12184D1D94E649E1PQ/1?acco
untid=13056 [Accessed 1 Mar 2016].
Prinjha, S. and Chapple, A. (2014) Patients’ experiences of living with an indwelling urinary
catheter. British Journal of Neuroscience Nursing. [Online] Vol.10 (2), p.62. Available:
http://web.b.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=2433065b-bfd9-43bb-9939f74285cb113b%40sessionmgr120&vid=1&hid=106 [Accessed 29 Feb 2016].
Pullen, R. (2005) Administering medication by the Z-track method. Nursing. [Online] Vol.35
(7), p.24. Available: EBSCOhost Biomedical Reference Collection: Comprehensive
[Accessed 21 Mar 2016].
Quayle, S. (2008) Observations. In: Richardson, R. (ed.). Clinical skills for student nurses:
Theory, practice, and reflection. Exeter: Reflect Press, pp.348–365.
Richardson, R. (2008) Catheterisation (male and female). In: Richardson, R. (ed.). Clinical
skills for student nurses: Theory, practice, and reflection. Exeter: Reflect Press, pp.171–184.
Rodger, M. A. and King, L. (2000) Drawing up and administering intramuscular injections: A
review of the literature. Journal of Advanced Nursing. [Online] Vol.31 (3), pp.574–82.
Available:
https://www.researchgate.net/publication/12596791_Drawing_up_and_administering_intram
uscular_injections_A_review_of_the_literature [Accessed 21 Mar 2016].
Roper, N., Logan, W. W. and Tierney, A. J. (2001) The Roper-Logan-Tierney model nursing.
Edinburgh: Churchill Livingstone.
Royal College of Nursing (2012) Catheter care. RCN guidance for nurses[Online]. Available:
https://www2.rcn.org.uk/__data/assets/pdf_file/0018/157410/003237.pdf [Accessed 29 Feb
2016].
Scottish Intercollegiate Guidelines Network (2012) Management of suspected bacterial
urinary tract infection in adults [Online]. Available: http://www.sign.ac.uk/pdf/sign88.pdf
[Accessed 16 Feb 2016].
Scottish Intercollegiate Guidelines Network (2014) Care of deteriorating patients [Online].
Available: http://www.sign.ac.uk/pdf/SIGN139.pdf [Accessed 5 Mar 2016].
23
Sisson, H. (2015) Aspirating during the intramuscular injection procedure: A systematic
literature review. Journal of Clinical Nursing. [Online] Vol.24 (17-18), pp.2368–2375.
Available: Wiley [Accessed 21 Mar 2016].
Steen, C. (2010) Prevention of deterioration in acutely ill patients in hospital. Nursing
Standard. [Online] Vol.24 (49), pp.49–57. Available: ProQuest Health [Accessed 22 Mar
2016].
Subbe, C. P., Davies, R. G., Williams, E., Rutherford, P. and Gemmell, L. (2003) Effect of
introducing the modified early warning score on clinical outcomes, cardio-pulmonary arrests
and intensive care utilisation in acute medical admissions. Anaesthesia. [Online] Vol.58 (8),
pp.797–802. Available: http://onlinelibrary.wiley.com/doi/10.1046/j.13652044.2003.03258.x/epdf [Accessed 6 Mar 2016].
Walsh, L. and Brophy, K. (2010) Staff nurses’ sites of choice for administering intramuscular
injections to adult patients in the acute care setting. Journal of Advanced Nursing. [Online]
Vol.67 (5), pp.1034–1040. Available: http://onlinelibrary.wiley.com/doi/10.1111/j.13652648.2010.05527.x/pdf [Accessed 26 Mar 2016].
Wilde, M. H. (2002) Urine flowing: A phenomenological study of living with a urinary
catheter. Research in Nursing & Health. [Online] Vol.25 (1), pp.14–24. Available:
http://onlinelibrary.wiley.com/doi/10.1002/nur.10020/epdf [Accessed 16 Feb 2016].
Wilde, M. H., Brasch, J. and Zhang, Y. (2011) A qualitative descriptive study of selfmanagement issues in people with long-term intermittent urinary catheters. Journal of
Advanced Nursing. [Online] Vol.67 (6), pp.1254–1263. Available:
http://web.a.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=a7aea757-8424-4bfb-8eec38571030ca92%40sessionmgr4005&vid=1&hid=4104 [Accessed 16 Feb 2016].
Wilhelm, F. H., Gevirtz, R. and Roth, W. T. (2001) Respiratory Dysregulation in anxiety,
functional cardiac, and pain disorders. Behaviour Modification. [Online] Vol.25 (4), pp.513–
545. Available:
http://bmo.sagepub.com/content/25/4/513.long?hwshib2=authn%3A1457449794%3A201603
07%253A6dc3a9c8-08cf-4d4e-9c6ab4a15a60330c%3A0%3A0%3A0%3AlwYGgJOYXisxd6YyAdBU1Q%3D%3D [Accessed 7
Mar 2016].
24
Willson, M., Wilde, M., Webb, M., Thompson, D., Parker, D., Harwood, J., Callan, L. and
Gray, M. (2009) Nursing interventions to reduce the risk of catheter-associated urinary tract
infection: Part 2: Staff education, monitoring, and care techniques. Journal of wound, ostomy,
and continence nursing: official publication of The Wound, Ostomy and Continence Nurses
Society / WOCN. Vol.36 (2), pp.137–54.
World Health Organization (2003) WHO European strategy for continuing education for
nurses and midwives [Online]. Available:
http://www.euro.who.int/__data/assets/pdf_file/0016/102238/E81549.pdf [Accessed 22 Mar
2016].
World Health Organisation (2015) WHO guideline on the use of safety-engineered syringes
for intramuscular, intradermal and subcutaneous injections in health-care settings [Online].
Available: http://www.who.int/injection_safety/global-campaign/injectionsafety_guidline.pdf?ua=1 [Accessed 17 Mar 2016].
Yuill, C., Crinson, I. and Duncan, E. (2010) Key concepts in health studies. London: SAGE
Publications.
Zaybak, A., Güneş, Ü. Y., Tamsel, S., Khorshid, L. and Eşer, İ. (2007) Does obesity prevent
the needle from reaching muscle in intramuscular injections? Journal of Advanced Nursing.
[Online] Vol.58 (6), pp.552–556. Available: JAN Original Research [Accessed 21 Mar
2016].
Zuckerman, J. N. (2000) The importance of injecting vaccines into muscle. British Medical
Journal. [Online] Vol.321 (7271), pp.1237–1238. Available:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1118997/ [Accessed 18 Mar 2016].
25