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Chronic kidney disease (CKD), also known as chronic renal failure (CRF), is a common, globally significant condition, with associated significant mortality and morbidity. Due to the disease prevalence, advanced clinical practitioners (ACPs) in a variety of primary and secondary care settings will encounter patients with this diagnosis who will require care and treatment. This article examines definitions of CKD, describes a clinical approach to a patient with CKD, including key history and examination findings, and provides a brief overview of renal replacement strategies for the patient with end-stage renal failure. ACPs require a thorough understanding of this condition and the key elements of treatment and care in this population.

This article outlines the role of the clinical nurse specialist in establishing a Scotland-wide national designated service for prostate cryotherapy for patients with radiation-recurrent prostate cancer. The service was established in 2009 and provides prostate cryotherapy across Scotland. This article reviews and discusses the challenges involved in setting up a new service for tertiary treatment as well as highlighting the key achievements of the service. The challenges have included introducing the cryotherapy procedure in a safe and quality assured manner, developing and refining the referral process, educating both primary and secondary care teams on salvage prostate cryotherapy as a treatment modality and surgical procedure, as well as managing of complications following salvage prostate cryotherapy. The article also outlines the achievements of both the service and the treatment as well as how the service has developed since 2009.

People in nursing and residential homes are more likely to suffer frailty. Registered nurses are a crucial component of the care delivery service and can offer support to patients who have complex care needs and comorbidities and are at risk of unplanned admissions to secondary care. This article explores frailty and the role of the nurse in assessing for frailty. Three aspects of patient care—nutrition status, polypharmacy and exercise and cognitive function—are discussed as areas where nurses can target their interventions in order to support those considered as frail, aiming to reduce the impact of frailty and negative health outcomes.

Background: antipyretic drugs are routinely administered to febrile patients with infection in secondary care. However, the use of antipyretics to suppress fever during infection remains a controversial topic within the literature. It is argued that fever suppression may interfere with the body's natural defence mechanisms, and may worsen patient outcomes. Method: a literature review was undertaken to determine whether the administration of antipyretic drugs to adult patients with infection and fever, in secondary care, improves or worsens patient outcomes. Results: contrasting results were reported; two studies demonstrated improved patient outcomes following antipyretic administration, while several studies demonstrated increased mortality risk associated with antipyretics and/or demonstrated fever's benefits during infection. Results also demonstrated that health professionals continue to view fever as deleterious. Conclusion: the evidence does not currently support routine antipyretic administration. Considering patients' comorbidities and symptoms of their underlying illness will promote safe, evidence-based and appropriate administration of antipyretics.

Hepatic encephalopathy (HE) can be a devastating complication of cirrhosis, affecting patients and their families. Multidisciplinary community and specialist teams must work together with patients and their families to recognise HE, identify and treat problems early, and minimise time spent unwell or in hospital. Primary care provides an ideal setting for patient education and reinforcement of the salient points on self-care. In the acute setting, the use of care pathways can ensure that the critical aspects of pharmacological, dietetic and supportive care are offered in a timely fashion to reduce morbidity and mortality. This article discusses strategies that can be used in primary and secondary care to help teams deliver excellent practice in HE management.

Respiratory tract infections (RTIs), including community-acquired pneumonia (CAP), bronchiolitis, viral-induced wheeze and croup, account for more primary care consultations than any other illness group and are the most likely reason for a parent or carer to contact a health professional. The majority of RTIs in fully immunised children are usually self-limiting. However, in a small percentage of children RTIs may become life threatening and it is crucial that all front-line health professionals are able to recognise and identify these children who are at risk of deterioration. To ensure this, fast recognition of symptoms is important, with care taken to exclude any ‘red flag’ features that may prompt a referral to secondary care. Nurses are well placed to reassure and support families, and to provide education regarding the facts about fever, the appropriate use of a single antipyretic medication, how to avoid dehydration in children with RTIs, and the beneficial role of immunisation in preventing infection. It is also important to explain in cases of CAP where antibiotics are necessary about how soon to expect a response, any side effects from antibiotics, and to provide ‘safety net advice’ on when to consider reassessment for the child. An illustrative case study is included to highlight some of the challenges that are likely to be encountered in clinical practice.

Acute secondary care settings are complex environments that offer a range of challenges for healthcare staff. These challenges can be exacerbated when patients present with a co-morbid mental illness. This article is a systematic review of the literature that has investigated the challenges imposed on health professionals working in acute secondary care settings where they care for patients who experience co-morbid physical and mental illnesses. A systematic search of the bibliographic databases was conducted and a total of 25 articles were included in this review. A number of challenges were identified including experience of fear, negative attitudes, poor mental health literacy, being positive and optimistic in providing care as a profession and environmental factors. Health professionals working in acute secondary care settings require organisational support and training in mental health care. Acute secondary care environments conducive to providing holistic care to patients experiencing mental illness co-morbidity are required.

Hepatitis C virus (HCV) is a significant public health threat in the UK, and is both underdiagnosed and undertreated. The treatment episode takes between 12 and 48 weeks. In the UK, HCV management is undertaken in secondary and tertiary centres. This does not meet the needs of all patients; they may have to travel long distances, incur travel costs, wait a long time to be seen and negotiate time off work while not divulging their illness. Providing care at home can increase patients’ access to and acceptability of treatment, especially in areas remote from specialist centres. This paper describes the feasibility, safety and efficacy of treating HCV infected patients at home by a partnership between secondary care and an clinical home care company. The home care model had a significantly higher attendance rate than the clinic model. It allowed the trust to improve care at no extra cost. This model can optimise specialist nurses’ time, allowing them to focus on patients with more complex needs.

In the current healthcare environment, clinicians are increasingly under pressure to use wound care products that are cost effective. This includes products that can be used in a variety of wounds to achieve different outcomes, depending on the wound-bed requirements. Medical-grade honey has emerged as a product that can achieve a variety of outcomes within the wound and is safe and easy to use. This article reviews the use of a medical-grade honey, with a view to including it on the wound care formulary in both primary and secondary care. It featured in a poster presentation at the Wounds UK conference at Harrogate in 2011.

The importance of the role of nutrition in wound healing is an area that has been widely explored over the last decade. It is well recognised that both macronutrients (protein, fat and carbohydrate) and micronutrients (vitamins, minerals and trace elements) play important parts in the healing of both chronic wounds and acute injuries. The term ‘wound’ encompasses many different situations from leg ulcers to laparostomy wounds. This article provides an overview of the role of different nutrients in the healing of wounds and guidance to nurses on first-line assessments, which can be used to ensure the patient is receiving adequate nutrition for successful wound healing. It will focus on commonly seen wounds in primary and secondary care but will not cover specialist wound management, such as laparostomy sites and burns, as these must always be cared for by experienced and specialist multidisciplinary teams.

Evidence-based patient care for those with urinary and faecal incontinence involves routine tasks that are integral to essential patient care. However, over the past few decades, researchers have demonstrated how ritualistic practice in this area has become. There is also a growing range of skin care products that can be used to prevent incontinence-associated dermatitis and for nurses, deciding which ones to use can be problematic Incontinent patients have a 22% higher risk of developing pressure ulcers – when immobile this risk increases to 30% – and the often indiscriminate use of various lotions, without a significant evidence base, is a growing cause of concern. Maintaining healthy skin for those patients who have a spinal cord injury and also experience urinary and faecal incontinence is a challenge faced by nurses in primary and secondary care. Research undertaken in secondary care demonstrates that standardization to an evidence-based skin care regime, to be used after incontinent episodes, improves patient care in this specialist area.

Currently, ‘shared decision making’, which involves the multidisciplinary team, i.e. the patient, nurse and doctor making joint decisions is advocated in many governing policies to improve the care of the dying patient. The UK population is ageing at an everincreasing rate, which means that more people are experiencing a progressive death typical of that associated with chronic disease. These patients are suitable for participation in end of life decision making due to the pre-existing knowledge of impending death. Health-care professionals can assist the patient to achieve a ‘good death’ based on the patient’s preferences, wishes and needs. The aim of the literature review discussed in this article was to identify the extent to which shared decision making currently exists during end of life care in the acute/hospice setting. Particular attention is paid to patient participation, the nurse’s role, and the doctor/nurse relationship – factors that may facilitate or prevent shared decision making. Eighteen qualitative research papers published between 1997–2007 were reviewed and analysed, and demonstrated a strong link between shared decision making and a ‘good death’. However, the research reviewed identified that although shared decision making can exist within end of life care, there are a number of reasons why this is not being achieved throughout the secondary care setting.

Osteoporosis is a chronic disease where the nurse specialist can make a significant impact. The osteoporosis nurse specialist has an important role, not only in the prevention and management of osteoporosis but also in the promotion of skeletal health across the public health and social care arenas and in the continuing development of services across primary and secondary care. The scale of the problem in women and the potential role of hormone replacement therapy in the prevention and treatment of osteoporosis has played down the problem of osteoporosis and osteoporotic fractures in men, thus facilitating a negligent attitude. This article summarizes the outcome of a dedicated male osteoporosis clinic, which was started by the lead clinicians in metabolic bone disease and falls and subsequently was run by the osteoporosis nurse specialist. A clinic proforma which can be used as a standard in clinical practice is presented. In addition, an algorithm for the management of men with osteoporosis is discussed.

In the last 14 years, research has identified that patients with heart failure suffer symptoms as severe as people with cancer and would greatly benefit from a palliative care approach. In spite of this fact, it is recognized within the National Service Framework for Heart Failure (Department of Health (DoH), 2000b) and the Cancer Plan (DoH, 2000a) that service provision from a palliative care perspective remains inadequate. In order to address the palliative care needs for patients with heart failure and their families a multidisciplinary team approach between primary and secondary care is needed. This article will review the literature relating to improvement of services from a palliative care perspective. It discusses the quality of life experienced by patients with heart failure and their families and the barriers to providing a palliative care approach from a multidisciplinary team perspective. Finally, it attempts to present future recommendations to develop a structured service provision.

This article concentrates on the practical management of those with seizures by general nurses. It focuses on the role of the hospital nurse in secondary care and the practice nurse in primary care. Both need to be conversant and practically competent to deal with the first-aid management of a seizure. They also need to know when medical assistance is required and how to act in an emergency. Epilepsy is a chronic long-term condition in adults and the main function of the nurse is advisory and educational. It is to act as a facilitator, and to assist adults to self-manage their epilepsy. Where the nurse is unable to provide this advice, appropriate referrals or contacts should be given.

The management of large cavity wounds has always posed particular challenges for nurses and clinicians. The National Institute for Clinical Excellence (NICE, 2001) suggests that the number of difficult-to-heal surgical wounds may increase in the future and that increased knowledge and expertise should be available across primary and secondary care. Recent research into wound healing has tended to focus on the biology of wound healing and manipulation of the healing processes with new dressings technology and other clinical and cost-effective treatments. Vacuum-assisted closure (VAC) is an innovation that is being given increasing attention. In Northampton, one patient nursed in the community setting has recently benefited from the technology to accelerate healing of a deep abdominal cavity. This article considers the historical management of cavity wounds and presents a case study. The feelings of the patient and the experiences of the district nurses in overcoming management problems are discussed. The case has proved to be the catalyst for a collaborative initiative across primary and secondary care services to ensure that all patients requiring the treatment are able to receive it in the community setting as well as in the hospital, when they are ready for discharge. It is recognized in Northampton that there are several applications for VAC in wound management and that the treatment has many benefits for patients and for those managing finite NHS resources.

T he UK Government’s initial response to the Francis Report, given in the House of Commons on 26 March by Mr Jeremy Hunt, Member of Parliament for South West Surrey and Secretary of State for Health in England, was brief. He did, I am very pleased to say, acknowledge that what went wrong at the Mid Staffs Trust was ‘Not typical and that the vast majority of doctors and nurses give excellent care day-in day-out’. Mr Hunt also noted that more time was needed to consider the report in full but that some response was required as a matter of urgency. A number of key areas for urgent action were identified and of course nursing loomed large among them. It is hard to disagree with much of the initial response, which focused on the need for compassionate care, zero harm, training for healthcare support workers, reducing frontline bureaucracy and a review of the complaints process. At last the Nursing and Midwifery Council (NMC) (and other professional regulators) were asked by Government to ‘tighten’ their procedures for dealing with cases of failure to adhere to professional standards. Some of you might share my view that ‘tightening’ does not come close to what needs to happen at the NMC and radical change to protect nurses as well as the public is long overdue. Sir Robert Francis said that the responsibility for what went wrong at Mid Staffs lies with the trust board. In response Mr Hunt says the Government will look at new legal sanctions at a corporate level for organisations that deliberately withhold information they are required to provide. It would have been helpful if he had assured us that board members would be required to have an understanding of the NHS before their appointment and some insight into what delivering safe compassionate care to millions of patients every day across primary community and secondary care actually means. It would also have been helpful to restate the need, as Sir Robert does (Recommendation 204) to have a nurse on the board of every healthcare organisation. Recommendation 187 from the Francis Report seems to have struck a particular chord with the Secretary of State and it appears already to be policy in the making. Recommendation 187 states

Choice is the new watchword in health care. But what does this really mean? Without adequate information and the right support from frontline health professionals, people struggle to understand their options. Primary and secondary care settings provide valuable opportunities to inform people about health needs, and nurses have an important role to play. The challenge, however, is to ensure that clinical services are geared up to deliver genuine choice and that health professionals are themselves informed enough to help patients assess what is right for them.

The recent Department of Health (DH) consultation document ‘Arrangements for the Provision of Dressings, Incontinence Appliances, Stoma Appliances, Chemical Reagents and Other Appliances to Primary and Secondary Care’ (2005), has caused a stir in more than one nursing field. Aside from the implications of change in the provision of stoma and incontinence devices, the commercial directorate of the DH appears to have on its agenda the reduction of wound dressing prices. There is a discrepancy between the reimbursement prices for primary and secondary care, there is also a discrepancy between the additional services provided by some companies and not others, such as support from company nurse advisors, help with case reports, patient information literature, education (both formal and informal), to name but a few examples.