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Shailen Jasani.

Make check lists part of everything you do

"Check lists are becoming quite sexy these days," said Shailen Jasani speaking at the BVNA Congress on the subject of 'The high-dependency medical case', "And I would encourage you to make them part of everything you do, every day."

The majority of high-dependency case management should be centred on proper patient care. Your first guide must be to answer the question, "How is my patient doing today?" This is not just the recitation of clinical read outs but a deeper understanding of the status of the major body systems – not just monitoring the patient's heart rate, for instance, but also feeling its pulse and the nature of that pulse.

When monitoring cases, focus on your physical examination and use everything else on top of that. Don't just process readings and simply write them down, but think about them and make sure you act upon them.

"Give analgesia before the pain comes," said Shailen. "And be interactional and dynamic with the patient to assess the pain by physical examination rather than just simple observation from across the other side of the room."

All medical cases require regular consideration of fluid balance under the two categories of perfusion and hydration. This can be quite a challenge and is often subjective.

It is vital to think ahead on a daily basis about the tests that are needed and make a plan so that the number of interventions are reduced to a minimum. "Think of it from the patient's point of view," said Shailen.

Enteral nutrition has to be used with care and gut tolerance is a major factor. If vomiting is a problem following tube feeding – but can be controlled by the use of an antiemetic –and overall gut function is working, then continue with it.

It is very important to monitor, clean and assess catheters and tubes constantly. Do they still need to be there? If not, then remove them. The same principle applies to wound management and bandages and dressings.

When it comes to drugs and antibiotics, more is not always better. Avoid an automatic daily incremental approach to medication. Does the patient still need all the agents being given or can some of them be stopped.

It is important to pay attention to more mundane aspects of the nursing, such as toileting, too. Does the patient still need the urinary catheter? Or is it simply acting as a focus for infection?

Another key factor that should be on the check list is mobility and physiotherapy. Are you set up to give the recumbent patient access to the outside to experience some fresh air? This can sometimes be more beneficial than just adding another drug to the list. In fact, high up on the check list is TLC and it is vital not to underestimate the value of uninterrupted, quality time spent with the high-dependency patient.

And finally, part of the nursing procedure must be the meticulous keeping of kennel charts. It is worth the time and they should be to a standard that anyone with an inkling of medical knowledge should be able to understand, even if they have not had any previous experience of the case.

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