Case Management

In Primary care emergencies are sent over from the doctors at any point of the day, the focus of this reflection is a young male that administration of a Nebuliser for 10 minutes (at doctors’ request) before being sent to hospital for further observation and treatment. A nebuliser is a machine that aids a person breathing of medication within mist though a mask or mouthpiece (British Lung Foundation, 2018).


When we get an emergency call from one of the doctors requesting a Nebuliser to be set up and administered to a patient, of any age, it is the doctor who initiates the dose, medication and length of time the patient needs to use the machine for whilst a registered nurse oversees the assembly and administration of the nebuliser (NHS Fife, 2012). So, when managing my own work during this, I first take down a note of the patient’s name, age, medication required, dosage of medication and for how long administration is required in line with the Rights of Administration of Medication (RCN, 2019). I then call into reception to make them aware so that the patient can be added to my caseload and, if it occurs during clinic, then they can rebook or reallocate patients where needed. This also means that reception is aware of the situation and is on standby in case an ambulance is needed to be called out. Monitoring the patient’s oxygen saturation (O2%) and pulse, measured by using a pulse oximeter, are the basic requests from a doctor when completing this task as part of the care programme for the patient.  Due to the range of ages that may need care to help aid with their health I treat all individuals with dignity, respect, compassion and caring throughout their time under my care as required within the 6C’s of nursing (RCN, 2015).

So What?

Nebuliser are normally used for patients who have asthma, COPD or are suffering with a shortness of breath (NHS Fife, 2012). The more normal choice of medication that is administered into the nebuliser are absorbed within the lungs as the patient breathes and release the alveoli (small sacks within the lungs) so that oxygen transfer between the lungs and bloods vessels and happen normally again (Wang et al, 2018). Due to the need of a nebuliser within primary care being on an urgent and/or emergency basis (Kelly, 2011), once a doctor makes a call to either bring the equipment to them or to take the patient into a separate room, I then need to be adaptable with my day in regards to organised clinics or stock check. If any clinics need to be arranged I call onto reception to go through my clinic and allocate work to colleagues that are able to undertake these appointments or advise current patients, that are waiting, that there will be a delay in being seen due to an emergency coming through and that they can either wait or rebook. Reception is aware that any issues can be called through to me or a colleague, if I am unable to pick up the phone. During the monitoring of the patient and after the nurse practitioner has overviewed the assemblance of the nebuliser, I have to keep a record of the readings of pulse and O2% using a pulse oximeter. A pulse oximeter is a small machine that is ideally attached to a patient index finger on either hand, but can be used on ear lobes of toes if unable to get a good reading (WHO, 2011). The machine measure who much oxygen is being transported throughout the body (BLF, 2017) and the ideal range is between 95 – 99%, any readings that are below this can identify if they are any issues with the lungs. However, patients with long term conditions like COPD (Chronic Obstructive Pulmonary Disease) have a desired range of 88 – 92% (NICE, 2010). This is done when they are in with doctor, before being put on the nebuliser and around ten minutes after being on the nebuliser (unless otherwise requested). Once these readings have been done, they are called through to the doctor and they make the clinical decision of sending the patient to hospital or further observation.

Now What?

Once the doctor has reviewed the readings, they then come up with a programme of care which is individualised to the patients’ health and care needs (NICE, 2012). Before completing the care plan for this patient the doctor will come down and, if able to, explain the different options that are available and their recommendation. If a patient is requiring hospital transport then the information, with regards to an ambulance requirement, is sent to reception that contact and arrange this. If they are able to get there via their own transport, and it is clinically safe to do so for them to travel within their own transport, then a letter is dictated by the doctor for the patient to take with them. Whilst this is all going on, I stay with the patient to make sure there are no sudden changes as well as to keep the patient calm and aware that they are being looked after and not just left alone so that if they have any questions or get progressively worse someone is notified quickly. This is also helpful if the doctor needs anything to be done urgently once they come down to review the patient with the readings. I will also sit with the patient and update staff with changes, if necessary, and help the ambulance team if needed or reaffirm the instructions of the doctor if they query before leaving the service. For example, reiterating the location they need to go to, if they are being taken by alternative transport other than ambulance or simply keeping them company whilst they wait for the transport with an empathetic approach whilst respecting their beliefs, culture and preferences. This was the case with this particular patient as their parent was distressed. So, to combat this I wrote down the area of the hospital they had to go to as well as making sure they had received their letter before departing the premises.

Supervision and Teaching

When a new HCA starts at the practice the senior HCA are tasked the responsibility of supervising, teaching, mentoring and assessing them with the skills they require within their limitations that are also within my own. After they have completed the required training days for the skills, they are then supervised within special clinics for them to develop their skill within practice after viewing them being done within practice. This is all done under the overall supervision of the Registered Practice Nurse and Practice Manager. International Normalised Ratio (INR) is a test completed on people who have conditions like Atrial Fibrillation or had a metallic valve placed in their heart (NICE, 2017). This is because they are on an anticoagulant medication like Warfarin Sodium which needs monitoring and maintenance to make sure the amount they are taking is not too much or too little (Shikdar, 2018), to avoid over clotting or reduced clotting resulting in bleeding out.


Once a new HCA has started within the practice, they are sent onto training courses by the Practice Manager and Practice Nurse to develop the theory and underpinning of the skills they will need within their role and learn to do them to best evidence-based practice. I will show them where all the protective equipment, dressings and stock are kept as well as go fundamental infection control measures i.e. hand washing during clinic appointments (NHS, 2017). Whilst within the practice, they will be shadowing a senior member of staff to see how these skills are utilised within the service environment whilst also developing their communication skills with patients and able to ask questions to confirm their current understanding (RCN, 2016). This helps them understand how we treat patients with respect and adapt our approach to them differently whilst respecting their beliefs, cultures, values and preferences (RCN, 2015). Before they go onto their INR training course, they will shadow myself during my clinics which will include International Normalised Ratio (INR) taking so that they already have an understanding of our practice procedure (Appendix A). This is a flow chart to help with the understanding of the individual steps required when completing this task. This skill is one of many and our procedure for each needs to be read or informed to new HCAs during their introduction time as well as supervision after training has been completed by an outside agency. INR goes towards their Health Care certificate which they need to acquire within the practice before completing clinics as an HCA (Skills for Health, n.d.).

So What?

I support the development of new HCA during their training by watching over them when they practice their newly learnt skills, once they have seen myself and colleagues do these skills a few times to gauge the difference in how people complete these tasks, whilst following the guidelines and procedures set up within the practice and by NICE guidelines (2017). After every practice, whilst doing an INR reading, and once the patient has left the clinic room, I give the new colleague honest feedback so that they know where they can improve and where they have done well. I prefer to do this once the patient has left the room so that they don’t feel embarrassed and are able to ask me additional questions so that they can do better in the future. This has been shown to be a better method of giving feedback as the receive doesn’t feel embarrassed and are able to take in the feedback completely rather than hold back their initial reaction (Hardavella, 2017). During consultations, that they are shadowing, I allow them full awareness that they can ask me any questions as this can help them fully understanding the reasoning why we do things in a certain way. I do this with an honest mannerism and am conscientious that there is always a reason why someone asks a question whether its for clarity or rectifying their current understanding. During INR taking I like to make sure that the HCA is constantly aware of where different medical products go after use so will generally quiz them on what goes where throughout their time with me at different times of the day or week. All of this goes towards their development and once they have completed ten separate INR appointments, where I feel they have completed them appropriately, then they get signed off on that skill, as long as they have done the day training, and can then complete these on their own with no supervision (Price-Dowd, 2017). I’m also fully aware that there may be times when I need to challenge what they are doing with courage when there is concern to make sure they are doing best practice and committed to learning and demonstrate discretion where needed.

Now What?

As part of our practice requirement, after completing training, any member of staff must complete the skill whilst being supervised for at least a minimum of ten occasions before being signed off as competent to do the skill without supervision (Price-Dowd, 2017). Now that I have signed them off as competent when I’ve watched them complete this and other skills, I then refer them to the Practice Manager and Practice Nurse for them to review their skills obtained and award them with their Health Care certificate (Skills in Health, n.d.). I will continue to mentor and assess them as they gain more skills to better help them with their career progression within the practice (RCN, n.d.). I will supervise them further in other skills they may need to undertake and refer them back to the Practice Manager and Practice Nurse when required. As we get new updates on skills practice and how they are meant to be carried out then I will need to update the HCA with the new information so that they are aware and advise the Practice Nurse and Practice Manager if they may need to resend HCA on courses. This may be because they have come to me as they are having issues completing a clinic task, even after showing competency within the mini clinics, if this happens then my teaching and mentoring will be reviewed as each skill requires a different method to gaining confidence within it. But they generally are fully competent with these skills and I will hold them back a little while if they feel they need a few more supervised sessions.



British Lung Foundation, 2018. Nebulisers; What is it? [online] Available at:  (Accessed 20th March 2019)

National Archives, 2018. Data Protection Act 2018 [online] Available at: (Accessed 20th March 2019)

RCN, 2015. 6C’s of nursing [online] Available at: (Accessed 2 April 2019)

British Lung Foundation, 2017. Breathing and lung function tests; Pulse oximetry test [online] Available at: (Accessed 2 April 2019)

NICE, 2010. Oxygen Saturation [online] Available at: (Accessed 2 April 2019)

NICE, 2012. Patient experience in adult NHS services: improving the experience [online] Available at: (Accessed 2 April 2019)

NHs, 2017. Hand washing hygiene. [online] Available at: (Accessed 2 April 2019)

Skills for Health, n.d. Care Certificate [online] Available at: (Accessed 2 April 2019)

NICE Guidelines, 2017. Warfarin Sodium [online] Available at: (Accessed 2 April 2019)

Price-Dowd, 2017. Being confident and competent is what makes the difference at the frontline. [online] Available at: (Accessed 2 April 2019)

RCN, n.d. Professional development [online] Available at: (Accessed 2 April 2019)

Shikdar, 2018. International Normalised Ratio (INR) [online] Available at: (Accessed 2 April 2019)

NICE, 2017. Anticoagulants – oral [online] Available at: (Accessed 2 April 2019)


Kelly, 2011. Best practice in the provision of nebuliser therapy. Nursing Standard. Volume 25 (Issue 31) pp.50-56

Wang et al, 2018. Pulmonary alveolar type 1 cell population consists of two distinct subtypes that differ in cell fate. PNAS. Volume 115 (Issue 10) pp. 2407 – 2412

Hardavella, 2017. How to give and receive feedback effectively. Breathe (Sheffield). Volume 13 (Issue 4) pp.327-333


NMC code, 2018 [PDF] London: Nursing and Midwifery Council. The Code Available at:  (Accessed 20 March 2019)

NHS Fife, 2012 [PDF] Essex: Fife Respiratory MCN. Nebuliser Guidelines Available at: (Accessed 27 March 2019)

WHO, 2011 [PDF] Patient Safety. Using Pulse Oximeters Available at: (Accessed 1 April 2019)

RCN, 2019 [PDF] London: Royal College of Nursing. Professional Guidance on the Administration of Medicines in Healthcare Settings Available at: (Accessed 27 March 2019)

RCN, 2016 [PDF] London: RCN. Supervision, accountability and delegation of activities to support workers Available at: (Accessed 2 April 2019)


Appendix A – Procedure for INR readings

Call the patient into room

Confirm patients D.O.B. and reason for appointment

Clean hands and place on PEE

Set up machine and insert testing strip into machine

Clean patients finger with single use alcohol wipe

Use single use lancet on finger, once dry

Apply gentle pressure around the area on the finger

Apply sample to the test strip and apply cotton ball to patients finger whilst asking them to apply pressure

Once machine has displayed reading record it into their record book and remove PEE

Speak to an appropriate prescriber about patient regime and next repeat of test

Relay information to patient and inform of next review date

Place test strip and cotton ball in appropriate disposable bin whist using appropriate PEE

Place machine back on stand

Remove and dispose of PEE and wash hands

Record information on patients record from reading and prescribers’ recommendation


D.O.B = Date of Birth

PEE = Protective equipment

This procedure flow chart was designed by myself as a result of helping new HCA learn how to do INR readings and was approved by the Practice Manager for use within the clinic rooms and for future supervision, teaching and mentoring of new clinical staff.

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