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INTRODUCTION TO THE CLINICAL PRACTICE GUIDELINES First Nations and Inuit Health Branch (FNIHB) Clinical Practice Guidelines for Nurses in Primary Care. The content of this chapter was revised in December 2011. Table of Contents PURPOSE .................................................................................................................I–1 STRUCTURE ............................................................................................................I–1 Format of Body System Chapters .......................................................................I–1 Format of Medical Diagnosis/Condition Descriptions .........................................I–1 CULTURE ..................................................................................................................I–2 Commonly Cited Value ........................................................................................I–2 Culture and Health ..............................................................................................I–2 Culture and Health Care .....................................................................................I–3 TRAUMA INFORMED CARE ....................................................................................I–4 COMMUNICATION ....................................................................................................I–4 Therapeutic Relationships ..................................................................................I–4 History Taking ......................................................................................................I–4 Use of an Interpreter ...........................................................................................I–6 Communication between Health Care Providers ................................................I–6 HEALTH ASSESSMENT ...........................................................................................I–7 Age Definitions ....................................................................................................I–7 History .................................................................................................................I–7 Physical Assessment ..........................................................................................I–9 CRITICAL THINKING ................................................................................................I–9 Establishing a Diagnosis .....................................................................................I–9 MANAGEMENT .......................................................................................................I–10 Non-Pharmacological Interventions ..................................................................I–10 Pharmacological Intervention Considerations ...................................................I–10 CLINICAL RESOURCES .........................................................................................I–11 Multidisciplinary Teams .....................................................................................I–11 Nursing Clinical Resources ..............................................................................I–11 Clinical Practice Guidelines for Nurses in Primary Care 2011 Introduction DOCUMENTATION .................................................................................................I–12 Objectives of Documentation ............................................................................I–12 Essential Components and Features ................................................................I–12 SOAP Documentation .......................................................................................I–13 CONSENT TO MEDICAL TREATMENT ..................................................................I–14 Refusal or withdrawal of consent ......................................................................I–14 Age of consent to medical treatment ................................................................I–14 When consent is impossible or impractical to obtain ........................................I–15 PRIVACY AND ACCESS ISSUES – RECORDS AND CONFIDENTIALITY ............I–15 General .............................................................................................................I–15 Disclosure of Personal Information ...................................................................I–15 Confidentiality ...................................................................................................I–17 APPENDIX A – SAMPLE DOCUMENTATION FOR A PEDIATRIC EPISODIC ASSESSMENT.......................................................I–18 APPENDIX B – SAMPLE DOCUMENTATION FOR A COMPREHENSIVE HEALTH ASSESSMENT .............................................I–20 SOURCES ...............................................................................................................I–23 2011 Clinical Practice Guidelines for Nurses in Primary Care Introduction I–1 PURPOSE The First Nations Inuit Health Branch Clinical The guidelines provide a broad range of topics Practice Guidelines for Nurses in Primary Care and health conditions aimed at complementing are practice tools designed to support community individual nurses’ self-assessment of knowledge, health nurses’ clinical decisions when delivering skills and judgment and do not necessarily represent primary health care within First Nations and Inuit provincially legislated scope of practice. In regions communities. As an educational tool, the guidelines where a transfer of authority is recognized by aim to support nursing practice for pediatric, regulatory bodies, the guidelines grant the registered adolescent and adult clients. nurse employed by Health Canada, limited authority to diagnose, request diagnostic tests (for example, The guidelines are based on best practices and laboratory tests and diagnostic imaging), and treat evidence available at the time they were written. They clients as per each health condition included in the are to be used in concert with regional and/or national guidelines. Provincial regulations, regional decisional guidelines, as well as the First Nations Inuit Health support tools, protocols, transfer of function or Branch Formulary and Drug Classification System, delegation tool may supersede this authority. the latter in regions where it is used. STRUCTURE The First Nations Inuit Health Branch Clinical FORMAT OF MEDICAL DIAGNOSIS/ Practice Guidelines for Nurses in Primary Care are CONDITION DESCRIPTIONS set up in a specific manner to make it easier for the users of the guidelines. The majority of the chapters in The chapters that describe medical diagnoses/ the guidelines are based on a specific body system and conditions describe each condition by using the then present the more common and associated medical following headings (if applicable to the condition): diagnoses/conditions. These chapters use the formats that follow. Medical Diagnosis/Condition – Causes FORMAT OF BODY – History SYSTEM CHAPTERS – Physical Findings – Differential Diagnoses Each chapter that corresponds to a body system is set – Complications up in the following format: – Diagnostic Tests – Management Assessment of the Body System – Cardinal Symptoms (in some chapters) – Goals of Treatment – History of Present Illness and Review of Systems – Appropriate Consultation – Physical Examination – Adjuvant Therapy – Nonpharmacologic Interventions Common Problems of the Body System – Pharmacologic Interventions – Conditions – Monitoring and Follow-Up Emergencies for the Body System – Referral – Conditions – Prognosis (present occasionally) Clinical Practice Guidelines for Nurses in Primary Care 2011 I–2 Introduction CULTURE1,2,3,4 Culture refers “to shared patterns of learned COOPERATION behaviours and values that are transmitted over time, Competition can interfere with group cohesiveness. and that distinguish the members of one group from Cooperation increases the sense of solidarity and another…. [It] can include: ethnicity, language, pools effort, talent and resources. religion and spiritual beliefs, gender, socio-economic class, age, sexual orientation, geographic origin, group EXCELLENCE history, education, upbringing and life experiences”.5 Each individual First Nations and Inuit community Gratitude is rarely shown or verbalized because each has their own specific culture which includes individual is expected to behave at a “normal” (that is, traditional and/or Western practices. They are diverse. excellent) level. The Inuit Way: A Guide to Inuit Culture can serve as an introduction to Inuit culture6 (available at: CULTURE AND HEALTH http://pauktuutit.ca/pdf/publications/pauktuutit/ Health beliefs and practices (traditional and/or InuitWay_e.pdf). Western) influence a client’s illness experience: how they define, understand and manage the COMMONLY CITED VALUES6 health problem. Mainly for purposes of illustration, some commonly Health for many First Nations and Inuit individuals cited values of First Nations and Inuit people are focuses on wholeness: achieving balance, strength given below. It must be emphasized that these values and interconnectedness of body, mind, emotions, and do not necessarily hold true for all First Nations and spirit. Each person is also linked to the health of the Inuit people and/or communities, but they do alert environment (for example, plants, animals, earth, the healthcare practitioner to the kinds of differences sky, water), community and family dependently and that can exist and to the possible consequences,
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