wiki/starter.py

"""Starter wiki content for the Nursing Knowledge Base.

This module provides a pre-seeded wiki covering core nursing knowledge,
aligned with NMC Standards of Proficiency (2018) and UK clinical frameworks.
"""

STARTER_WIKI = {
    "articles": {
        "nmc_code": {
            "title": "The NMC Code",
            "category": "standards",
            "tags": ["nmc", "professional", "code", "ethics", "accountability"],
            "last_updated": "2026-04-04",
            "sources": ["built-in"],
            "content": """# The NMC Code

The **NMC Code** (2015, updated 2018) sets out the professional standards that registered nurses, midwives and nursing associates must uphold. It is structured around four themes.

## The Four Themes

### 1. Prioritise People
- Treat people as individuals and uphold their dignity
- Listen to people and respond to their preferences and concerns
- Make sure people's physical, social and psychological needs are assessed and responded to
- Act in the best interests of people at all times
- Respect and uphold people's rights to make their own decisions

### 2. Practise Effectively
- Always practise in line with the best available evidence
- Communicate clearly — maintain clear and accurate records
- Work cooperatively — work with colleagues to evaluate the quality of your work
- Share your skills, knowledge and experience for the benefit of people receiving care and your colleagues
- Keep your knowledge and skills up to date throughout your working life

### 3. Preserve Safety
- Recognise and work within your own competence
- Be open and candid with all service users about all aspects of care — **Duty of Candour**
- Act without delay in situations that put people at risk
- Raise concerns immediately if you believe a person is vulnerable or at risk
- Advise on, prescribe, supply, dispense or administer medicines within the limits of your training and competence

### 4. Promote Professionalism and Trust
- Uphold the reputation of your profession at all times
- Uphold your position as a registered nurse, midwife or nursing associate
- Fulfil all registration requirements
- Cooperate with all investigations and audits

## Key Accountability Principles

- You are **personally accountable** for your actions and omissions in your practice
- Delegation does not remove your accountability as the registered nurse
- You must **escalate concerns** using local policies (e.g. Datix, RIDDOR) without delay
- The NMC can take action if your fitness to practise is impaired

## Related Articles
- [[NMC Proficiency Standards 2018]]
- [[Duty of Candour]]
- [[Delegation in Nursing]]
- [[NMC Revalidation]]

## References
- NMC (2018) *The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates*. London: NMC.
""",
        },
        "nmc_proficiency": {
            "title": "NMC Standards of Proficiency 2018",
            "category": "standards",
            "tags": ["nmc", "proficiency", "standards", "competency", "registration"],
            "last_updated": "2026-04-04",
            "sources": ["built-in"],
            "content": """# NMC Standards of Proficiency 2018

The **NMC Standards of Proficiency for Registered Nurses** (2018) set out what all nursing students must know, understand, and be able to do at the point of registration. They are organised into seven platforms plus Annexes A and B.

## The Seven Platforms

### Platform 1: Being an Accountable Professional
Nurses act in the best interests of people, making evidence-based decisions and maintaining professional standards. Includes reflective practice, escalation of concerns, and accountability.

### Platform 2: Promoting Health and Preventing Ill Health
Understanding public health, health promotion, and disease prevention. Includes social determinants of health, health screening, and vaccination programmes.

### Platform 3: Assessing Needs and Planning Care
Using evidence-based assessment frameworks and tools. Includes systematic assessment (ABCDE, NEWS2), holistic needs assessment, and care planning (ADPIE).

### Platform 4: Providing and Evaluating Care
Delivering and evaluating safe, effective, person-centred care. Includes clinical skills, therapeutic interventions, and outcome measurement.

### Platform 5: Leading and Managing Nursing Care and Working in Teams
Prioritisation, delegation, and inter-professional working. Includes team leadership, conflict management, and workload management.

### Platform 6: Improving Safety and Quality of Care
Patient safety principles, clinical governance, and quality improvement. Includes incident reporting, risk assessment, and audit.

### Platform 7: Coordinating Care
Coordinating complex care across teams and organisations. Includes discharge planning, referral processes, and integrated care pathways.

## Annexe A: Communication and Relationship Management Skills
Therapeutic communication, breaking bad news, working with interpreters, health literacy.

## Annexe B: Nursing Procedures
The practical skills all registered nurses must demonstrate, organised by body system:
- Wound care and pressure ulcer prevention
- Venepuncture and cannulation
- Medication administration
- Catheterisation
- Moving and handling
- Vital signs monitoring (including NEWS2)

## Field-Specific Standards
The generic standards apply across all four fields:
- **Adult nursing**
- **Mental health nursing**
- **Learning disabilities nursing**
- **Children's nursing**

Field-specific proficiencies build on the generic standards.

## Related Articles
- [[The NMC Code]]
- [[ABCDE Assessment]]
- [[NEWS2 - National Early Warning Score]]
- [[ADPIE - The Nursing Process]]
- [[NMC Revalidation]]

## References
- NMC (2018) *Future Nurse: Standards of Proficiency for Registered Nurses*. London: NMC.
""",
        },
        "abcde_assessment": {
            "title": "ABCDE Assessment Framework",
            "category": "clinical",
            "tags": ["assessment", "abcde", "deteriorating patient", "clinical", "emergency"],
            "last_updated": "2026-04-04",
            "sources": ["built-in"],
            "content": """# ABCDE Assessment Framework

The **ABCDE approach** is the systematic method for assessing and managing acutely ill or deteriorating patients. It is recommended by the Resuscitation Council UK and underpins NEWS2 escalation.

## The Five Components

### A — Airway
**Goal**: Ensure the airway is patent (open and unobstructed).

- Look for signs of airway obstruction: gurgling, stridor, paradoxical chest movement
- Assess for secretions, foreign body, swelling, or positional compromise
- **Interventions**: Head-tilt chin-lift, jaw thrust, suction, airway adjuncts (nasopharyngeal, oropharyngeal), call anaesthetist for advanced airway
- If airway is compromised, call for help immediately (**2222 in hospital**)

### B — Breathing
**Goal**: Assess adequacy of ventilation and gas exchange.

- **Inspect**: rate (normal 12–20/min), depth, symmetry, use of accessory muscles
- **Palpate**: tracheal position, chest expansion
- **Percuss**: dullness (consolidation/effusion), hyper-resonance (pneumothorax)
- **Auscultate**: air entry, added sounds (wheeze, crackles, pleural rub)
- **Measure**: SpO₂ (target 94–98%; 88–92% in COPD), peak flow if asthma
- **Interventions**: positioning (upright), oxygen therapy, nebulisers, call for review

### C — Circulation
**Goal**: Assess cardiovascular status and perfusion.

- **Heart rate**: normal 60–100 bpm; note rhythm (regular/irregular)
- **Blood pressure**: systolic <90 mmHg = hypotension; >140/90 = hypertension
- **Capillary refill time (CRT)**: normal <2 seconds; press sternum or fingertip
- **Skin**: temperature, colour, turgor, diaphoresis
- **Urine output**: normal >0.5 mL/kg/hr
- **12-lead ECG** if cardiac arrhythmia suspected
- **Interventions**: IV access, fluid challenge, catheter for urine output monitoring

### D — Disability
**Goal**: Assess neurological status.

- **AVPU scale**: Alert, Voice, Pain, Unresponsive
- **GCS (Glasgow Coma Scale)**: Eyes (4), Verbal (5), Motor (6) — normal = 15
- **Blood glucose**: BM/CBG — hypoglycaemia (<4 mmol/L) is a medical emergency
- **Pupillary response**: size, equality, reactivity to light
- **Limb movement**: power and sensation
- **Interventions**: glucose correction, neurological referral, seizure management

### E — Exposure
**Goal**: Identify all clinical problems; avoid missing findings.

- Fully expose the patient while maintaining dignity and warmth
- Check skin: rashes, wounds, oedema, pressure areas, surgical drains, IV sites
- Temperature: pyrexia (>38°C), hypothermia (<36°C)
- Examine abdomen: distension, tenderness, bowel sounds
- Prevent hypothermia: warm blankets, warm IV fluids if needed

## SBAR Handover After ABCDE
After completing ABCDE, communicate findings using **SBAR**:
- **S**ituation: who you are, about whom, the problem
- **B**ackground: relevant history, medications
- **A**ssessment: your ABCDE findings
- **R**ecommendation: what you need from the senior/team

## Related Articles
- [[NEWS2 - National Early Warning Score]]
- [[SBAR Communication]]
- [[Sepsis Recognition and Management]]
- [[Oxygen Therapy]]

## References
- Resuscitation Council UK (2021) *The ABCDE approach*. resus.org.uk
- Smith, G. (2010) *In-hospital cardiac arrest: Is it time for an in-hospital chain of prevention?* Resuscitation 81(9): 1209–1211.
""",
        },
        "news2": {
            "title": "NEWS2 - National Early Warning Score",
            "category": "clinical",
            "tags": ["news2", "early warning", "deteriorating patient", "escalation", "vital signs"],
            "last_updated": "2026-04-04",
            "sources": ["built-in"],
            "content": """# NEWS2 — National Early Warning Score

**NEWS2** is the standardised early warning score recommended by NHS England and NICE (NG94, 2018) for identifying acutely ill adults in hospital and pre-hospital settings. It replaced NEWS1 and is mandatory across NHS trusts.

## The Seven Parameters Scored

| Parameter | Range | Score |
|-----------|-------|-------|
| Respiration rate (breaths/min) | ≤8 | 3 |
| | 9–11 | 1 |
| | 12–20 | 0 |
| | 21–24 | 2 |
| | ≥25 | 3 |
| SpO₂ Scale 1 (%) | ≤91 | 3 |
| | 92–93 | 2 |
| | 94–95 | 1 |
| | ≥96 | 0 |
| SpO₂ Scale 2 (COPD target 88–92%) | ≤83 | 3 |
| | 84–85 | 2 |
| | 86–87 | 1 |
| | 88–92 or ≥93 on air | 0 |
| Air or oxygen? | Oxygen | 2 |
| | Air | 0 |
| Systolic BP (mmHg) | ≤90 | 3 |
| | 91–100 | 2 |
| | 101–110 | 1 |
| | 111–219 | 0 |
| | ≥220 | 3 |
| Pulse (bpm) | ≤40 | 3 |
| | 41–50 | 1 |
| | 51–90 | 0 |
| | 91–110 | 1 |
| | 111–130 | 2 |
| | ≥131 | 3 |
| Consciousness | Alert | 0 |
| | CVPU (New confusion, Voice, Pain, Unresponsive) | 3 |
| Temperature (°C) | ≤35.0 | 3 |
| | 35.1–36.0 | 1 |
| | 36.1–38.0 | 0 |
| | 38.1–39.0 | 1 |
| | ≥39.1 | 2 |

## Clinical Response Thresholds

| Score | Risk | Response |
|-------|------|---------|
| 0 | Low | Routine obs (minimum 12-hourly) |
| 1–4 | Low | Increase monitoring; nurse to assess |
| 3 in one parameter | Low-Medium | Nurse to urgently inform ward doctor |
| 5–6 | Medium | Urgent doctor review; consider HDU |
| ≥7 | High | Emergency response — 2222 arrest call |

**New onset confusion** (C in CVPU) scores 3 — even if other obs are normal, this must trigger urgent review.

## Important Caveats

- **SpO₂ Scale 2**: Use only for patients with confirmed hypercapnic respiratory failure (usually COPD) with a prescribed target of 88–92%
- **Pregnancy**: Standard NEWS2 is **not validated** in pregnancy — use MEOWS (Modified Early Obstetric Warning Score)
- **Children**: Use PEWS (Paediatric Early Warning Score) — not NEWS2
- NEWS2 is a **trigger**, not a diagnosis — always use clinical judgement alongside the score

## Escalation and Documentation

1. Calculate NEWS2 at every observation set
2. Document on NEWS2 chart/in EPR
3. Escalate according to trust protocol (SBAR handover)
4. If in doubt — escalate; it is always better to call unnecessarily

## Related Articles
- [[ABCDE Assessment Framework]]
- [[Sepsis Recognition and Management]]
- [[SBAR Communication]]
- [[Vital Signs - Normal Ranges]]

## References
- Royal College of Physicians (2017) *National Early Warning Score (NEWS) 2*. London: RCP.
- NICE (2018) *NG94: Sepsis: recognition, diagnosis and early management*. London: NICE.
""",
        },
        "adpie": {
            "title": "ADPIE - The Nursing Process",
            "category": "clinical",
            "tags": ["adpie", "nursing process", "care planning", "assessment", "evaluation"],
            "last_updated": "2026-04-04",
            "sources": ["built-in"],
            "content": """# ADPIE — The Nursing Process

**ADPIE** is the five-step nursing process used to deliver individualised, evidence-based care. It provides a systematic, cyclical framework for clinical decision-making.

## The Five Steps

### A — Assessment
**Purpose**: Gather comprehensive, holistic data about the patient.

**Subjective data** (what the patient tells you):
- Chief complaint, symptoms, pain (SOCRATES), history of presenting complaint
- Past medical history, medications, allergies
- Functional status, social history, cultural and spiritual needs

**Objective data** (what you observe and measure):
- Vital signs, NEWS2, physical examination
- Laboratory and diagnostic results
- Behavioural and psychological observations

**Tools**: ABCDE, NEWS2, nutritional screening (MUST), falls risk (Morse), pressure ulcer risk (Braden/Waterlow), pain scales (NRS, Wong-Baker)

### D — Diagnosis (Nursing Diagnosis)
**Purpose**: Identify actual and potential nursing problems.

Use **NANDA-I** nursing diagnoses (not medical diagnoses):
- **Actual problem**: "Acute pain related to surgical incision as evidenced by facial grimacing and verbal report of 8/10 pain"
- **Risk problem**: "Risk for infection related to compromised skin integrity"
- **Health promotion**: "Readiness for enhanced self-management"

Structure: **Problem + Related to (aetiology) + As evidenced by (signs/symptoms)**

Prioritise using **Maslow's Hierarchy**: physiological → safety → love/belonging → esteem → self-actualisation

### P — Planning
**Purpose**: Set measurable goals and select interventions.

**SMART Goals**:
- **S**pecific, **M**easurable, **A**chievable, **R**elevant, **T**ime-bound
- Example: "Patient will report pain ≤3/10 within 30 minutes of analgesia administration"

**Short-term goals**: within hours/days (acute care)
**Long-term goals**: discharge and rehabilitation focused

Document planned interventions and rationale.

### I — Implementation
**Purpose**: Carry out the planned interventions.

Types of nursing interventions:
- **Independent**: actions within nursing scope without medical order (e.g., repositioning, education)
- **Dependent**: require medical order (e.g., medications, investigations)
- **Collaborative/Interdependent**: with other health professionals (e.g., physiotherapy referral)

Document all care delivered, responses, and changes.

### E — Evaluation
**Purpose**: Determine whether goals have been met and revise the plan.

- Compare patient outcomes to the goals set in Planning
- **Goal met**: document and continue
- **Partially met**: identify barriers; modify interventions
- **Not met**: reassess; revise nursing diagnosis and plan

Evaluation is **continuous**, not just at discharge. ADPIE is cyclical — re-assessment triggers a new cycle.

## Documentation in ADPIE
All five steps must be documented in patient records per:
- NMC Code (2018): accurate, contemporaneous records
- Local trust policies and EPR systems
- GDPR and Caldicott Principles (patient confidentiality)

## Related Articles
- [[ABCDE Assessment Framework]]
- [[NANDA Nursing Diagnoses]]
- [[Person-Centred Care]]
- [[Documentation Standards]]

## References
- NMC (2018) *Future Nurse: Standards of Proficiency for Registered Nurses*. Platform 3.
- Alfaro-LeFevre, R. (2019) *Critical Thinking, Clinical Reasoning, and Clinical Judgment*. 7th ed. Elsevier.
""",
        },
        "nine_rights": {
            "title": "The Nine Rights of Medication Administration",
            "category": "pharmacology",
            "tags": ["medication", "safety", "nine rights", "drug administration", "pharmacology"],
            "last_updated": "2026-04-04",
            "sources": ["built-in"],
            "content": """# The Nine Rights of Medication Administration

The **Nine Rights** (expanded from the traditional Five Rights) provide a framework for safe medication administration. They are a core component of **NMC Proficiency** and the **NMC Code**.

## The Nine Rights

### 1. Right Patient
- Verify identity using at least **two identifiers**: name + date of birth (not bed number)
- Check patient ID band against the prescription chart/EPR
- Ask the patient to state their name and DOB (if conscious and able)
- **Never** rely on verbal confirmation alone or room/bed location

### 2. Right Drug (Medication)
- Check the drug name against the prescription: beware **LASA** (Look-Alike Sound-Alike) drugs
- Know the drug: indication, mechanism, therapeutic range
- Check for allergies — cross-reference allergy record before administration
- Confirm with BNF or local formulary if unsure

### 3. Right Dose
- Calculate the dose: **Dose = Desired / Have × Volume**
- Verify dose is within normal therapeutic range
- For high-alert medications (e.g., heparin, insulin), a second registered nurse must independently double-check
- Weight-based dosing: confirm current weight; recalculate for paediatric patients

### 4. Right Route
- Confirm prescribed route (oral, IV, IM, SC, topical, inhaled, PR, etc.)
- Ensure the formulation matches the route (e.g., never give oral solution intravenously)
- Modified-release preparations must never be crushed

### 5. Right Time
- Administer at the correct prescribed time
- Understand time-critical medications (e.g., antibiotics in sepsis within 1 hour, insulin, anticoagulants)
- Document time of administration promptly

### 6. Right Documentation
- Record immediately after administration (not before)
- Sign/initial the prescription chart or EPR at time of administration
- If medication not given, document reason with appropriate code

### 7. Right Reason
- Understand *why* the patient is receiving this medication
- Confirm the indication is still appropriate
- Question prescriptions you do not understand — prescribers have a duty to explain

### 8. Right Response
- Monitor patient after administration for therapeutic effect and adverse reactions
- Know expected onset and duration of action
- Know the signs of adverse effects and anaphylaxis
- Document patient response

### 9. Right Refusal
- Patients have the right to refuse medication (Mental Capacity Act 2005 / Gillick competence for children)
- Document refusal clearly; inform the prescriber
- Explore reasons for refusal; do not coerce

## Double-Checking Policy
High-alert medications typically require two registered nurses to independently:
- Calculate the dose
- Check the drug, concentration, route, and rate (for infusions)
- Prepare and administer

Refer to local trust policy for the list of drugs requiring double-checking.

## Related Articles
- [[ISMP High-Alert Medications]]
- [[Drug Calculations]]
- [[Mental Capacity Act 2005]]
- [[Medication Safety - LASA Drugs]]
- [[Anaphylaxis Management]]

## References
- NMC (2018) *Future Nurse: Standards of Proficiency*, Annexe B.
- ISMP (2023) *List of High-Alert Medications*. ismp.org
- BNF (current edition). bnf.nice.org.uk
""",
        },
        "drug_calculations": {
            "title": "Drug Calculations",
            "category": "pharmacology",
            "tags": ["drug calculations", "dosage", "iv rate", "weight-based", "maths"],
            "last_updated": "2026-04-04",
            "sources": ["built-in"],
            "content": """# Drug Calculations

Accurate drug calculations are a core NMC competency. All nurses must be able to perform these calculations safely and accurately.

## Core Formulae

### 1. Tablets / Capsules
```
Number of tablets = What you WANT ÷ What you HAVE
```
**Example**: Prescribed 75 mg, available 25 mg tablets → 75 ÷ 25 = **3 tablets**

### 2. Liquid Oral / Injectable Medications
```
Volume to give = (What you WANT ÷ What you HAVE) × Volume of stock
```
**Example**: Prescribed 250 mg, available 500 mg/5 mL → (250 ÷ 500) × 5 = **2.5 mL**

### 3. IV Drip Rate (Drops per Minute)
```
Drops per minute = (Volume (mL) × Drop factor) ÷ Time (minutes)
```
- Standard giving set: **20 drops/mL**
- Blood/viscous fluids: **15 drops/mL**
- Microdrop set: **60 drops/mL**

**Example**: 1000 mL over 8 hours (480 min) using standard set → (1000 × 20) ÷ 480 = **41.7 ≈ 42 drops/min**

### 4. IV Flow Rate (mL per Hour — for infusion pump)
```
Rate (mL/hr) = Volume (mL) ÷ Time (hours)
```
**Example**: 500 mL over 6 hours → 500 ÷ 6 = **83.3 mL/hr**

### 5. Weight-Based Dosing
```
Dose = Prescribed dose (mg/kg) × Patient weight (kg)
```
**Example**: Prescribed 5 mg/kg, patient weighs 70 kg → 5 × 70 = **350 mg**

### 6. Concentration / Infusion Rate
```
Rate (mL/hr) = [Dose (mcg/kg/min) × Weight (kg) × 60] ÷ Concentration (mcg/mL)
```
**Example**: Noradrenaline 0.1 mcg/kg/min, 80 kg patient, 4 mg in 50 mL (= 80 mcg/mL)
→ (0.1 × 80 × 60) ÷ 80 = 480 ÷ 80 = **6 mL/hr**

### 7. Percentage Concentrations
- **w/v (weight in volume)**: grams per 100 mL → 0.9% NaCl = 0.9 g per 100 mL
- **v/v (volume in volume)**: mL per 100 mL

### 8. Unit Conversions
| From | To | Multiply by |
|------|----|-------------|
| grams (g) | milligrams (mg) | × 1,000 |
| milligrams (mg) | micrograms (mcg) | × 1,000 |
| micrograms (mcg) | nanograms (ng) | × 1,000 |
| litres (L) | millilitres (mL) | × 1,000 |

**Always convert to the same units before calculating.**

## Checking Your Answer
1. Does it seem clinically reasonable? (e.g., >10 tablets is a red flag)
2. For IV rates: cross-check by working backwards
3. High-risk drugs: always have a second registered nurse independently verify

## Common Errors to Avoid
- Decimal point errors (e.g., 1.5 mg vs 15 mg)
- Unit confusion (mg vs mcg — 1000× difference)
- Miscalculating rate for variable-rate infusions (e.g., sliding scale insulin)
- Using an incorrect patient weight (use current measured weight)

## Paediatric Considerations
- Always use **current weight** (weighed today, not estimated)
- Use **Broselow tape** in emergencies for estimated weight
- Paediatric doses are **always weight-based**
- Maximum adult doses apply — never exceed even if calculation gives higher
- Use paediatric BNF (BNFc) or local formulary

## Related Articles
- [[The Nine Rights of Medication Administration]]
- [[ISMP High-Alert Medications]]
- [[Insulin Administration]]
- [[IV Therapy and Fluid Management]]

## References
- NMC (2018) *Future Nurse: Standards of Proficiency*, Annexe B.
- BNF/BNFc (current edition). bnf.nice.org.uk / bnfc.nice.org.uk
- Wright, K. (2009) *Drug calculations for nurses*. Nursing Standard 23(28): 35–40.
""",
        },
        "pico_framework": {
            "title": "PICO Framework for Evidence-Based Practice",
            "category": "evidence",
            "tags": ["pico", "ebp", "evidence", "research", "clinical question"],
            "last_updated": "2026-04-04",
            "sources": ["built-in"],
            "content": """# PICO Framework for Evidence-Based Practice

**PICO** is the structured format for formulating clinical questions to guide evidence searches. It is foundational to Evidence-Based Practice (EBP) in nursing.

## The PICO Components

| Letter | Stands For | Question to Ask |
|--------|-----------|-----------------|
| **P** | Population / Patient / Problem | Who is the patient? What is the condition/problem? |
| **I** | Intervention | What is the main intervention, treatment, or exposure? |
| **C** | Comparison | What is the main alternative (if any)? |
| **O** | Outcome | What are you trying to achieve or measure? |

## Example PICO Question

**Clinical scenario**: An elderly patient with a pressure ulcer on their heel. You wonder whether hydrocolloid dressings are better than foam dressings.

| Component | Example |
|-----------|---------|
| P | Adults aged ≥65 with Category II pressure ulcers |
| I | Hydrocolloid dressings |
| C | Foam dressings |
| O | Wound healing time, pain, infection rates |

**PICO question**: "In adults aged ≥65 with Category II pressure ulcers (P), do hydrocolloid dressings (I) compared to foam dressings (C) reduce wound healing time and infection rates (O)?"

## PICO Variations

### PICOT (adding Time)
- **T**: Time — over what period is the outcome measured?
- Useful for longitudinal studies or time-sensitive outcomes

### PICOS (adding Study design)
- **S**: Study design — what type of study is most appropriate?
- Useful when you want to specify RCT, cohort study, etc.

### PEO (Qualitative questions)
For qualitative research: **P**opulation, **E**xposure/Experience, **O**utcome
- "What are the experiences (O) of patients with chronic pain (P) regarding acupuncture (E)?"

## Using PICO for Database Searching

1. Identify PICO components
2. Generate **synonyms and MeSH terms** for each component
3. Use **Boolean operators**: AND (between components), OR (between synonyms)
4. Apply **filters**: date range, language, study type, human subjects

**Search string example**:
`("pressure ulcer" OR "pressure injury" OR "decubitus ulcer") AND ("hydrocolloid" OR "occlusive dressing") AND ("foam dressing") AND ("wound healing" OR "ulcer healing")`

## Levels of Evidence (Melnyk Hierarchy)

| Level | Study Type |
|-------|-----------|
| I | Systematic review / Meta-analysis of RCTs |
| II | Well-designed RCT |
| III | Controlled trial without randomisation |
| IV | Case-control or cohort study |
| V | Systematic review of descriptive/qualitative studies |
| VI | Single descriptive or qualitative study |
| VII | Expert opinion, clinical guidelines, consensus |

Always seek the **highest level of evidence** available for your question.

## Related Articles
- [[Evidence-Based Practice - The Five Steps]]
- [[Critical Appraisal Tools]]
- [[Systematic Reviews and Meta-Analysis]]
- [[Database Searching for Nursing Research]]

## References
- Melnyk, B.M. & Fineout-Overholt, E. (2019) *Evidence-Based Practice in Nursing & Healthcare*. 4th ed. Lippincott.
- Richardson, W.S. et al. (1995) The well-built clinical question: a key to evidence-based decisions. ACP Journal Club 123(3): A12.
""",
        },
        "person_centred_care": {
            "title": "Person-Centred Care",
            "category": "frameworks",
            "tags": ["person-centred", "care", "framework", "mccormack", "dignity", "holistic"],
            "last_updated": "2026-04-04",
            "sources": ["built-in"],
            "content": """# Person-Centred Care

**Person-centred care** places the individual — their values, preferences, and goals — at the centre of all care decisions. It is a core principle of the NMC Code, NHS Long Term Plan (2019), and Health Education England frameworks.

## Core Principles

1. **Respect for individuality**: Recognise each person's unique needs, values, beliefs, and preferences
2. **Shared decision-making**: Involve people in decisions about their own care; provide information to enable informed choice
3. **Therapeutic relationship**: Build trust through empathy, genuineness, and unconditional positive regard (Carl Rogers)
4. **Holistic care**: Address physical, psychological, social, spiritual, and cultural needs
5. **Continuity and coordination**: Ensure seamless care across settings and over time

## McCormack & McCance Person-Centred Nursing Framework (2010, updated 2017)

Four constructs:

### 1. Prerequisites (Nurse Attributes)
Professional competence, interpersonal skills, commitment to the job, clarity of beliefs and values, self-awareness.

### 2. Care Environment
Appropriate skill mix, shared decision-making systems, effective staff relationships, supportive organisational systems, physical environment.

### 3. Person-Centred Processes
- Working with the patient's beliefs and values
- Engaging authentically
- Being sympathetically present
- Sharing decision-making
- Providing holistic care

### 4. Outcomes
Patient satisfaction, involvement in care, feeling of well-being, therapeutic culture.

## Six Cs of Nursing (NHS, 2012 — Compassion in Practice)

| C | Definition |
|---|-----------|
| **Care** | Core business of nursing |
| **Compassion** | Empathy; how care is delivered |
| **Competence** | Technical and clinical skills + knowledge |
| **Communication** | Effective, clear, respectful |
| **Courage** | Doing the right thing; speaking up |
| **Commitment** | To patients, profession, and outcomes |

## Barriers to Person-Centred Care
- Time pressures and high workloads
- Hierarchical institutional culture
- Lack of staff training in communication
- Electronic systems that depersonalise care
- Negative attitudes and burnout

## Legal and Ethical Foundations
- **Mental Capacity Act 2005**: Presumption of capacity; involve people in decisions; best interests if no capacity
- **Human Rights Act 1998**: Article 8 (right to private and family life); Article 3 (freedom from degrading treatment)
- **Equality Act 2010**: Nine protected characteristics; duty to make reasonable adjustments

## Related Articles
- [[The NMC Code]]
- [[Mental Capacity Act 2005]]
- [[Communication Skills in Nursing]]
- [[ADPIE - The Nursing Process]]
- [[Dignity in Care]]

## References
- McCormack, B. & McCance, T. (2017) *Person-Centred Practice in Nursing and Health Care*. 2nd ed. Wiley-Blackwell.
- NHS England (2019) *The NHS Long Term Plan*. NHS England.
- Rogers, C. (1961) *On Becoming a Person*. Houghton Mifflin.
""",
        },
        "mental_capacity_act": {
            "title": "Mental Capacity Act 2005",
            "category": "law",
            "tags": ["mental capacity", "law", "mca", "consent", "best interests", "deprivation of liberty"],
            "last_updated": "2026-04-04",
            "sources": ["built-in"],
            "content": """# Mental Capacity Act 2005

The **Mental Capacity Act (MCA) 2005** is the legal framework for making decisions for people who may lack capacity to make decisions for themselves. It applies to everyone aged 16+ in England and Wales.

## The Five Statutory Principles

1. **A person must be assumed to have capacity** unless it is established otherwise
2. **A person is not to be treated as unable to make a decision** unless all practicable steps to help them have been taken without success
3. **A person is not to be treated as unable to make a decision** merely because they make an unwise decision
4. **An act done or decision made** for a person who lacks capacity must be done in their **best interests**
5. Before an act or decision is taken, regard must be had to whether the purpose can be as effectively achieved in a way that is **less restrictive** of the person's rights and freedom of action

## Two-Stage Capacity Assessment

### Stage 1: Is there an impairment or disturbance of mind or brain?
- Dementia, brain injury, mental health condition, delirium, unconsciousness, intoxication
- This is **time-specific** and **decision-specific**

### Stage 2: Does the impairment affect their ability to make THIS decision?
A person lacks capacity if they cannot do **one or more** of:
- **Understand** the information relevant to the decision
- **Retain** that information long enough to make the decision
- **Use or weigh** the information as part of the decision-making process
- **Communicate** the decision (by any means)

**Document the assessment clearly in patient records.**

## Best Interests Decision-Making

When a person lacks capacity, decisions must be made in their **best interests**:
- Consider the person's past and present wishes, feelings, values and beliefs
- Consult carers, family members, and anyone named by the person
- Consider less restrictive options
- Hold a **best interests meeting** for complex decisions

## Key Roles

| Role | Who | Powers |
|------|-----|--------|
| **Lasting Power of Attorney (LPA)** | Appointed by person while capacitous | Health & welfare, property & finance (separate LPAs) |
| **Court-Appointed Deputy** | Appointed by Court of Protection | Usually property/finance; rarely health |
| **Independent Mental Capacity Advocate (IMCA)** | Statutory advocate | Serious medical treatment for unbefriended patients |

## Deprivation of Liberty Safeguards (DoLS) / Liberty Protection Safeguards (LPS)

People in care homes and hospitals who lack capacity may be **deprived of their liberty** only under legal authorisation:
- **DoLS**: authorised by local authority; applies in care homes and hospitals
- **LPS**: replacing DoLS (planned but delayed); applies wider settings
- **Community Deprivation of Liberty**: requires Court of Protection order (Re X)

## Advance Decisions

- **Advance Decision to Refuse Treatment (ADRT)**: legally binding refusal of specific treatment in specific circumstances, made while capacitous
- Must be in writing, signed, and witnessed for life-sustaining treatment
- **Advance Statement**: preferences; not legally binding but must be considered in best interests

## Related Articles
- [[The NMC Code]]
- [[Consent in Nursing]]
- [[Person-Centred Care]]
- [[Safeguarding Adults]]
- [[Duty of Candour]]

## References
- Mental Capacity Act 2005. legislation.gov.uk
- Department of Health (2005) *Mental Capacity Act Code of Practice*. The Stationery Office.
- NMC (2018) *The Code*. Section 4.2.
""",
        },
        "infection_control": {
            "title": "Infection Prevention and Control",
            "category": "safety",
            "tags": ["infection control", "hand hygiene", "ppe", "standard precautions", "ipc", "hcai"],
            "last_updated": "2026-04-04",
            "sources": ["built-in"],
            "content": """# Infection Prevention and Control

Infection Prevention and Control (IPC) is a fundamental nursing responsibility. Healthcare-associated infections (HCAIs) affect 1 in 15 NHS patients at any time (NICE, 2014).

## Standard Precautions (apply to ALL patients, ALL the time)

Standard precautions assume that **all blood, body fluids, secretions, excretions, non-intact skin, and mucous membranes** may be infectious.

### 1. Hand Hygiene — The Single Most Important IPC Measure

**WHO 5 Moments for Hand Hygiene:**
1. **Before** patient contact
2. **Before** a clean/aseptic procedure
3. **After** body fluid exposure risk
4. **After** patient contact
5. **After** contact with patient surroundings

**Technique:**
- Alcohol-based handrub (ABHR): 20–30 seconds — preferred when hands are visibly clean
- Soap and water: 40–60 seconds — mandatory when hands are visibly soiled, before eating, and after caring for patients with *Clostridioides difficile* or *norovirus*

**Six-step technique** (Ayliffe method):
1. Palm to palm
2. Right palm over left dorsum (and vice versa)
3. Palm to palm, fingers interlaced
4. Backs of fingers to opposing palms (interlocked)
5. Rotational rubbing of right thumb in left palm (and vice versa)
6. Rotational rubbing of fingertips of right hand in left palm (and vice versa)

Nails kept short, no nail varnish or artificial nails, no rings/watches/bracelets.

### 2. Personal Protective Equipment (PPE)

| Risk Level | Minimum PPE |
|-----------|-------------|
| Low risk (no contact with blood/body fluids) | Apron + gloves |
| Splash risk (procedures, wound care) | Apron + gloves + fluid-resistant surgical mask + eye protection |
| Aerosol Generating Procedure (AGP) | Gown + gloves + FFP3 respirator + eye protection |
| Contact precautions (MRSA, VRE) | Apron + gloves (+ gown for high risk) |

**Donning order**: Hand hygiene → gown → mask/respirator → eye protection → gloves
**Doffing order**: Gloves → hand hygiene → gown/apron → eye protection → mask → hand hygiene

### 3. Safe Management of Sharps
- Never re-sheath needles
- Dispose of sharps at point of use into sharps bin (not more than ¾ full)
- Never pass sharps hand-to-hand
- Report needlestick injuries immediately: first aid (encourage bleeding, wash with running water), complete incident form, occupational health

### 4. Waste Management
| Waste Type | Colour Code | Example |
|-----------|-------------|---------|
| Infectious clinical waste | Yellow | Dressings, PPE, used sharps |
| Cytotoxic/cytostatic | Purple | Chemotherapy waste |
| Domestic | Black/grey | Non-clinical waste |
| Confidential | Black (with marking) | Patient records |
| Sharps | Yellow sharps bin | All needles, blades |

## Transmission-Based Precautions

Applied **in addition to** standard precautions for specific organisms:

| Route | Organisms | Additional Precautions |
|-------|-----------|----------------------|
| **Contact** | MRSA, VRE, *C. difficile*, scabies | Side room, dedicated equipment, gloves + apron |
| **Droplet** | Influenza, meningococcal, streptococcal | Side room, surgical mask, gloves + apron |
| **Airborne** | TB, measles, chickenpox, COVID-19 (AGP) | Negative pressure side room, FFP3 respirator |

## Common HCAIs in the UK
- **MRSA** (Meticillin-resistant *Staphylococcus aureus*) — skin, surgical wounds, bloodstream
- **C. difficile** — antibiotic-associated diarrhoea; spore-forming; only soap and water (NOT ABHR)
- **CAUTI** — catheter-associated urinary tract infection; minimise catheter use
- **CLABSI** — central line-associated bloodstream infection; aseptic technique
- **SSI** — surgical site infection; pre-op bundles

## Chain of Infection

Break **any** link to prevent infection:
```
Infectious agent → Reservoir → Portal of exit → Mode of transmission → Portal of entry → Susceptible host
```

## Related Articles
- [[Hand Hygiene - WHO Technique]]
- [[Catheter Care (CAUTI Prevention)]]
- [[MRSA Management]]
- [[C. difficile Management]]
- [[Sepsis Recognition and Management]]

## References
- WHO (2009) *Guidelines on Hand Hygiene in Health Care*. WHO Press.
- NICE (2014, updated 2017) *NG125: Healthcare-associated infections: prevention and control in primary and community care*.
- NHS England (2022) *National Infection Prevention and Control Manual (NIPCM)*. england.nhs.uk
""",
        },
        "duty_of_candour": {
            "title": "Duty of Candour",
            "category": "safety",
            "tags": ["duty of candour", "candour", "openness", "transparency", "incident", "apology", "francis"],
            "last_updated": "2026-04-04",
            "sources": ["built-in"],
            "content": """# Duty of Candour

**Duty of Candour** is the professional and statutory obligation to be open and honest with patients when things go wrong. It was introduced following the **Francis Report (2013)** into Mid Staffordshire NHS Foundation Trust.

## Two Layers of Duty

### 1. Professional Duty (NMC, individual nurses)
Under the **NMC Code (2018)**, all registered nurses must:
- Act without delay if they believe that there is a risk to patient safety (clause 16)
- Raise and escalate concerns immediately (clause 17)
- Be open and honest and act with integrity (clause 23)
- Be open and candid with the people in their care — including when things go wrong (clause 24)

### 2. Statutory Duty (NHS organisations)
Under **Regulation 20** of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, NHS trusts must, as soon as reasonably practicable after a **notifiable safety incident**:
1. Notify the patient (or their representative) in person
2. Provide a written **apology** (an apology is not an admission of legal liability)
3. Provide a truthful account of all that is known about the incident
4. Explain what enquiries are being undertaken
5. Follow up in writing

## What is a Notifiable Safety Incident?
An incident that, in the reasonable opinion of a registered professional, could result in (or has resulted in) **moderate harm, severe harm, prolonged psychological harm, or death**.

## What Duty of Candour Requires in Practice

1. **Tell the patient** what happened as soon as possible after the incident
2. **Apologise**: "I am sorry this happened" — this is **not** an admission of liability
3. Provide **truthful information** about what happened and what is being done
4. **Do not mislead** patients — even by omission
5. **Document** all communications with the patient regarding the incident
6. **Support the patient** — identify what support is available

## Barriers to Candour (why it sometimes fails)
- Fear of litigation
- Fear of disciplinary action
- Institutional culture of blame
- Lack of training in disclosure conversations
- Hierarchy and power imbalances

## Supporting Framework: SBAR + Datix
- Use **SBAR** to escalate concerns
- Complete a **Datix** (or equivalent incident report) contemporaneously
- Involve the **PALS** (Patient Advice and Liaison Service) if appropriate

## Related Articles
- [[The NMC Code]]
- [[Incident Reporting (Datix)]]
- [[Patient Safety Culture]]
- [[Safeguarding Adults]]

## References
- Francis, R. (2013) *Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry*. The Stationery Office.
- NMC (2018) *The Code*, clause 24.
- CQC (2014) *Regulation 20: Duty of Candour*. legislation.gov.uk
""",
        },
        "ebp_framework": {
            "title": "Evidence-Based Practice — The Five Steps",
            "category": "evidence",
            "tags": ["ebp", "evidence-based", "clinical question", "pico", "research", "sackett"],
            "last_updated": "2026-04-04",
            "sources": ["built-in"],
            "content": """# Evidence-Based Practice — The Five Steps

**Evidence-Based Practice (EBP)** is "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients" (Sackett et al., 1996). It integrates:
- **Best available external evidence** (research)
- **Clinical expertise** (professional judgement)
- **Patient preferences and values**

## The Five-Step EBP Process

### Step 1: Ask — Formulate the Clinical Question
Convert the clinical problem into a searchable, answerable question using **PICO** (or PICOT/PEO for qualitative questions).

**Example**: "In adults with type 2 diabetes (P), does structured self-management education (I) compared to standard care (C) improve glycaemic control (HbA1c) (O) over 12 months (T)?"

### Step 2: Acquire — Search for Evidence
Search databases systematically:
- **MEDLINE/PubMed** (biomedical literature)
- **CINAHL** (nursing and allied health)
- **Cochrane Library** (systematic reviews)
- **NICE Evidence** (clinical guidelines)
- **BNF** (pharmacological evidence)
- **NHS Evidence / OpenAthens**

Apply filters: date, language, study type, human subjects.

### Step 3: Appraise — Critical Appraisal
Evaluate the evidence for **validity, importance, and applicability**:
- **CASP tools** (Critical Appraisal Skills Programme): RCT checklist, systematic review checklist, qualitative checklist
- **GRADE framework**: quality of evidence — High / Moderate / Low / Very Low
- **Cochrane Risk of Bias tool** (for RCTs)
- **Newcastle-Ottawa Scale** (for cohort/case-control studies)

Key appraisal questions:
1. Is the study design appropriate for the question?
2. Are the methods valid and the results reliable?
3. What are the results, and are they clinically significant?
4. Are the results applicable to my patient?

### Step 4: Apply — Integrate Evidence with Clinical Expertise and Patient Values
- Integrate the evidence with your clinical experience
- Discuss evidence with the patient: their preferences, circumstances, and values must be considered
- Consider local factors: resources, trust protocols, patient population
- Share decision-making

### Step 5: Evaluate — Assess the Outcome
- Monitor patient outcomes after applying the evidence
- Audit clinical practice against the evidence
- Share findings with colleagues (clinical governance, journal clubs)
- Feed back into the EBP cycle

## Levels of Evidence
See [[PICO Framework]] for Melnyk's seven-level hierarchy.

## EBP in the NMC Standards
- **Platform 1** (Accountable Professional): practise in line with best available evidence
- **Platform 3** (Assessment): use evidence-based assessment tools
- **Platform 6** (Safety & Quality): contribute to clinical audit and quality improvement

## Related Articles
- [[PICO Framework for Evidence-Based Practice]]
- [[Critical Appraisal Tools (CASP)]]
- [[Systematic Reviews and Meta-Analysis]]
- [[Clinical Guidelines — NICE, SIGN, BTS]]

## References
- Sackett, D.L. et al. (1996) Evidence based medicine: what it is and what it isn't. BMJ 312: 71–72.
- Melnyk, B.M. & Fineout-Overholt, E. (2019) *Evidence-Based Practice in Nursing & Healthcare*. 4th ed. Lippincott.
- CASP (2022) *Critical Appraisal Skills Programme checklists*. casp-uk.net
""",
        },
        "safeguarding": {
            "title": "Safeguarding Adults and Children",
            "category": "law",
            "tags": ["safeguarding", "abuse", "neglect", "children", "adults", "law", "section 47"],
            "last_updated": "2026-04-04",
            "sources": ["built-in"],
            "content": """# Safeguarding Adults and Children

Safeguarding is everyone's responsibility. Nurses have a statutory and professional duty to recognise, report, and respond to abuse and neglect.

## Safeguarding Adults

### Legal Framework
- **Care Act 2014**: Local authorities have a duty to investigate safeguarding concerns for adults at risk
- **Care and Support Statutory Guidance (2014, updated 2023)**
- **Mental Capacity Act 2005**: Protects people who lack capacity

### Who is an Adult at Risk?
An adult (18+) who:
- Has care and support needs (regardless of whether they receive services)
- Is experiencing, or is at risk of, abuse or neglect
- Cannot protect themselves because of their care and support needs

### Types of Abuse (Care Act 2014)
1. Physical abuse
2. Domestic violence/abuse
3. Sexual abuse
4. Psychological/emotional abuse
5. Financial/material abuse
6. Modern slavery
7. Discriminatory abuse
8. Organisational/institutional abuse
9. Neglect and acts of omission
10. Self-neglect

### The Six Principles of Adult Safeguarding
**Empowerment, Prevention, Proportionality, Protection, Partnership, Accountability**

### Making a Safeguarding Referral (Adults)
1. Identify concern — use SBAR to articulate
2. Inform your manager/senior immediately
3. Do not investigate yourself
4. Make a referral to the local authority safeguarding team
5. Document the concern clearly and factually
6. If immediate danger: call 999 first

## Safeguarding Children

### Legal Framework
- **Children Act 1989**: "Children's welfare is paramount"
- **Children Act 2004**: Section 11 — duty to cooperate to safeguard children
- **Working Together to Safeguard Children (2023)**: Multi-agency guidance
- **Keeping Children Safe in Education (2023)**

### Categories of Abuse (Children)
1. Physical abuse
2. Emotional abuse
3. Sexual abuse
4. Neglect

### Child Protection Process
1. **Concern**: Nurse identifies signs/disclosure of abuse
2. **Report**: Immediately to Named Nurse for Safeguarding or manager
3. **Section 47 enquiry**: Local authority + police investigate (if child at risk of significant harm)
4. **Child Protection Conference**: Multi-agency decision
5. **Child Protection Plan**: If child needs ongoing protection

### Signs of Abuse — General Indicators
- Unexplained injuries or bruising inconsistent with explanation
- Changes in behaviour (withdrawal, aggression, fearfulness)
- Disclosure — always take seriously and never promise confidentiality
- Signs of neglect (poor hygiene, hunger, inappropriate clothing)
- Sexualised behaviour beyond developmental stage

## What to Do If Someone Discloses

1. **Listen** — do not interrupt or ask leading questions
2. **Believe** — take the disclosure seriously
3. **Reassure** — tell them they were right to tell you
4. **Explain confidentiality limits** — you must share information to protect them
5. **Report immediately** — inform manager/senior; make a safeguarding referral
6. **Document** — verbatim what was said, using the person's own words
7. **Do not investigate or confront** the alleged abuser

## Related Articles
- [[The NMC Code]]
- [[Mental Capacity Act 2005]]
- [[Duty of Candour]]
- [[GDPR and Patient Confidentiality]]

## References
- Care Act 2014. legislation.gov.uk
- HM Government (2023) *Working Together to Safeguard Children*. gov.uk
- NMC (2018) *The Code*, clause 17.
""",
        },
    },
    "log": [
        "## [2026-04-04] system | Nursing Knowledge Base initialised with 14 starter articles across 6 categories."
    ],
    "index_summary": """# Nursing Knowledge Base — Index

This wiki covers core nursing knowledge aligned with NMC Standards of Proficiency (2018).

## Categories

### standards
- **[[The NMC Code]]** — Four themes: prioritise people, practise effectively, preserve safety, promote professionalism
- **[[NMC Standards of Proficiency 2018]]** — Seven platforms + Annexes A and B; registration requirements

### clinical
- **[[ABCDE Assessment Framework]]** — Systematic approach: Airway, Breathing, Circulation, Disability, Exposure
- **[[NEWS2 - National Early Warning Score]]** — Seven-parameter early warning score; escalation thresholds
- **[[ADPIE - The Nursing Process]]** — Assessment, Diagnosis, Planning, Implementation, Evaluation

### pharmacology
- **[[The Nine Rights of Medication Administration]]** — Patient, Drug, Dose, Route, Time, Documentation, Reason, Response, Refusal
- **[[Drug Calculations]]** — Tablets, liquids, IV rate, drip rate, weight-based, concentration formulae

### evidence
- **[[PICO Framework for Evidence-Based Practice]]** — Formulating clinical questions; Melnyk evidence hierarchy
- **[[Evidence-Based Practice — The Five Steps]]** — Ask, Acquire, Appraise, Apply, Evaluate (Sackett)

### frameworks
- **[[Person-Centred Care]]** — McCormack & McCance framework; Six Cs; MCA, Human Rights Act

### safety
- **[[Infection Prevention and Control]]** — Standard precautions, hand hygiene (5 moments), PPE, transmission routes
- **[[Duty of Candour]]** — Professional and statutory duty; Francis Report; what to say and do

### law
- **[[Mental Capacity Act 2005]]** — Five principles, two-stage capacity test, best interests, DoLS/LPS
- **[[Safeguarding Adults and Children]]** — Care Act 2014, Children Act 1989, types of abuse, referral processes
""",
    "sources": {},
    "metadata": {
        "created": "2026-04-04",
        "version": "1.0",
        "article_count": 14,
        "organisation": "Nursing Citizen Development Organisation",
    },
}


def get_starter_wiki():
    """Return a deep copy of the starter wiki."""
    import copy
    return copy.deepcopy(STARTER_WIKI)