Welcome to the Acute Stroke, Rehabilitation & Haematology Unit The information within this package is designed to provide a useful introduction to rehabilitation and medical nursing. Please set some time aside to read the provided information and ask if you have any queries about the contents. General Ward Information The Unit is a 22 bedded (16 Stroke / Rehab. & 6 Haematology) mixed sex adult medical ward specialising in Acute Stroke, Rehabilitation and Haematology. There is a strong emphasis on neurological conditions i.e. Strokes, Parkinson's disease and Multiple Sclerosis. During your time on the ward you will have the opportunity to nurse individuals with a wide variety of needs and medical problems. We admit patients from the Emergency Assessment Unit, Accident and Emergency, Intensive Care, other wards and hospitals. Patients transferred within the hospital can often be assessed prior to coming to the ward by an MDT member; this is to ensure they are suitable / appropriate for the unit. On the unit all staff pride ourselves on maintaining high quality fundamental nursing care, which is current and evidence based, this will become evident during your placement with us... As a team, all staff are very proud to be part of an ever improving unit, seeing our Ward Manager, Sister Julie Brown receive an MBE in the ‘2014’ New Years Honours list for services to Stroke and General Nursing. Mission Statement ‘To provide the individual with a high quality service which is flexible and responsive to the clients’ needs as well as being cost effective’? Ward Philosophy ‘We believe rehabilitation and acute care should be planned according to the individual patient's needs, with an ultimate goal of achieving the highest level of personal independence, maximum integration into the community and the most satisfying quality of life compatible with their disability.’ Student Philosophy ‘During your placement you will have a variety of opportunities to enhance your skills and make your stay with us beneficial to your educational needs. We often invite a speaker to give updates / provide information etc. which is appropriate to the ward needs. We have ward based Clinical Nurse Specialists who will be very happy for you to spend some time with them. The ward also has an excellent multidisciplinary team who are always very willing for you to spend some time with them. We very much want you to enjoy your time with us, learn as much as possible and meet all your outcomes. Please do see your mentor or a member of staff if you have any concerns or queries no matter how small they are.’ History of the unit / Charter Mark The development of an Acute Stroke and TIA Service with minimal resources. Aim Nevill Hall Hospital is a district general hospital in the heart of Abergavenny, a Welsh market town. It is one of three District General Hospitals in Gwent Healthcare NHS Trust serving a largely rural population of 300,000 people. On average 350 - 400 new strokes and 200 TIAs are referred to Nevill Hall for assessment, investigations and treatment each year. The 'Acute Stroke Service' is provided by all members of a multidisciplinary team based on an acute stroke ward. In addition the service is complimented by full co-operation from radiology, pharmacology, vascular technology and pathology departments. Up until 10 years ago the care offered to these patients was disorganised and random. It lacked leadership and co-ordination, but most importantly the service did not have an acute stroke unit. Stroke patients were scattered amongst general medical or care of the elderly wards and did not receive therapy or care from any personnel with a special knowledge or interest in stroke. The service needed a leader and a geographically identified area that could form a stroke unit. The results of the 1998 RCP Sentinel Stroke Audit demonstrated that overall Nevill Hall was performing well below the national average in caring for stroke patients. In particular; i. Only 44% of patients received CT <24 hours ii. Only 34% of patients weighed during admission iii. Only 55% of patients had their swallowing assessed within 72 hours of admission iv. Only 14% had risk factors discussed with them v. Only 25% had diagnosis and prognosis discussed with them vi. No evidence that carers' needs were assessed Complaints were high and staff morale was low. Staff on the care of the elderly/rehabilitation unit lacked a speciality that they could excel in and battled to prevent inappropriate patients being admitted to their ward. Methodology In 2000 a care of the elderly consultant was nominated as the stroke lead and the only funding that was made available, was to appoint a Clinical Nurse Specialist for acute stroke care. With vision and enthusiasm, a sign declaring 'An Acute Stroke Unit' was placed above the door of the existing rehabilitation ward signalling the birth of the Acute Stroke Service. It was agreed that all stroke patients, whatever their age of disability, could and should be admitted to the Acute Stroke Unit. The following developments took place without resource enhancement; • Lead Consultant for Stroke identified • Appointed Clinical Nurse Specialist for Stroke • Dysphagia screen training - Qualified nurses • Direct admissions to Stroke Unit • Integrated Stroke Pathway introduced • Weekly Carers' Clinic on the Stroke Unit • Fast-Track system all strokes to Stroke Consultant • Weekly TIA Clinics • Protected mealtimes • Vascular examinations on site • CT slots allocated for stroke patients • Charter Mark Award for Acute Stroke Service • 7 day CT scanning piloted successfully • 1000 Lives Campaign highlighted absence of Complaints Results Regular auditing of the service provided Sentinel Audits 2002/2004/2006/2008 (above median average) 2004 Sentinel Audit; • 50% patients received CT < 24 hours • 92% patients weighed during admission • 98% patients treated in the stroke unit • 92% scored with communication with patients and carers • Overall top in Wales TIA audit Dysphasia audit 7 day CT scan audit Awarded the governments Charter Mark Award 2006 (Recognition of a public service from clients and users perspective) Evaluation The Stroke Service has successfully evolved without additional monies over a period of 10 years: 1. Stroke patients are now admitted directly to a stroke unit under the care of the lead consultant for stroke. 2. They are able to receive their CT head scan within 24 hours, 7 days a week. 3. All qualified nurses are trained to perform dysphagia screening as soon as patients are able. 4. The ward sister carries out a carers' clinic every week, listening to both patients and their carers' concerns. 5. Protected mealtimes have been introduced so that patients are offered peace and privacy to maximise their nutritional intake. 6. TIA clinics are held most week days, in order to reduce the length people have to wait. 7. Carotid Doppler scanning is now performed on site and at the same time as TIA clinic. Reflection Networking with other areas of excellence helps to visualise your goals. We have listened to the patients and their carers, regularly reviewing their needs and expectations and acting upon them. We worked with other disciplines and departments within the hospital to reconfigure the service including radiology and vascular departments. We worked closely with our partners in the community; Primary Care, Social Services and the Voluntary Sector. Further action Keep trying - never give up. Do not let the lack of resources get you down. Energy, clear multidisciplinary objectives, enthusiasm and a motivated workforce is worth far more than money. A lot can be achieved within the available resources. Haematology Haematology is quite a new speciality to the unit, we inherited 6 haematology beds on the unit approximately three years ago, and we liaise with Windsor Suite (Haematology Day unit, NHH). Holding these beds has provided excellent learning opportunities for all staff, increasing our knowledge and competence within nursing. Haematology patients can become acutely ill very quickly; therefore we have a system on the unit whereby we can instigate direct admission to the unit from home for these patients, if deemed necessary. The types of patients we see are those with Lymphoma or Myeloma. Often these patients are post chemotherapy and therefore can be neutropenic. When admitted they often require reverse barrier nursing, and commencement on the neutropenic sepsis pathway. Many of these patients have Hickman / Pic Lines. The Nursing Staff Sister Julie Brown MBE, is the Ward Manager, running the ward with assistance from the rest of the team. We use a team nursing approach in order to provide continuity of care for the patients. We aim to provide high quality; evidence based nursing care, always following national guidelines and trust policies. We believe it important to include family and friends where possible. The staff will vary in experience and time qualified, you will have the opportunity to work with a variety of them during your placement , this includes Staff and Auxiliary Nurses, Physiotherapists, Occupational Therapists, Rehab Assistants and other MDT members. The staff aims to provide a supportive learning environment for students, but if you have any difficulties or queries please speak to someone as soon as possible about it so we can help you. Nursing Skills The skills required by rehabilitation nurses are vast. There is presently no definition of the overall role of a rehabilitation nurse but many suggestions have been put forward by various authors. The kinds of activities in which a nurse may engage in during the early stages of rehabilitation are: protecting skin against tissue breakdown (inc. assessing and dressing wounds) positioning to prevent nerve damage, pain and abnormal limb function maintenance of fluid and nutritional intake (inc. NG and PEG feeding) helping with elimination maintaining personal hygiene administering medication (promoting self medication) communicating with significant others promoting patient advocacy within the MDT As the patient becomes more independent they will begin to take on more responsibility of these activities and the nurse must learn to take a more 'hands off' approach to patient care. It is hoped that the patient will become totally independent in some areas, but if this is not possible the patient should be encouraged to make decisions regarding their care. For example, they may not be physically able to get their clothes out of the wardrobe but they are capable of choosing what they want to wear. There are Nurses on the ward who have a special interest in specific areas i.e. continence, wound care, diabetes, and health and safety etc. They will be happy to help you. Learning Opportunities available depending on your individual needs Managing Nutrition PEG feeding (becoming confident in setting up a PEG feed) Naso-Gastric (NG) feeding Fundamental Patient Care Working with the Multidisciplinary Team (MDT) Attend MDT meetings and ward rounds Observing speech and swallow assessments Learning to communicate with patients who have problems with communication (i.e. speech/hearing/visual problems) Continence Care – The Continence Nurse Specialist liaises with the ward frequently to offer support and advice Monitoring of essential observations - blood pressure, pulse, respirations, oxygen saturation and temperature Sending specimens to pathology To be aware of policies and procedures at ward level which are also available on the Intranet Be involved in administration of medications - Intravenous, Subcutaneous, oral and via PEG or NG Become familiar with ward documentation To be familiar with all the manual handling equipment available on the ward Windsor Suite Thrombolytic therapy Care of Hickman / Pic lines Rehabilitation The ward is a designated area for rehabilitation. Patient rehabilitation incorporates many aspects such as protected meal times, visiting and rest. There is no set time that a patient may stay on the ward, some patients may stay for a few days and others a few weeks, it depends on their rehabilitation needs and social requirements before discharge. A patient's discharge often requires involvement from many of the members of the MDT. Rehabilitation is designed to enable the patient to achieve an optimum level of functioning. Its aim is to minimise handicap resulting from impairment and provide them with an acceptable standard of living. The nurse has many roles in the co-ordination of rehabilitation, many of which you will become responsible and accountable for. For example: liaise with patients and carers initiate contact with other team members give and receive information from and to all involved in rehabilitation administer prescribed therapy take part in assessing, planning, implementing and evaluating of goals encourage and support the patients and carers Rehabilitation requires certain skills if it is going to be successful for the patient, carers and nurses. These are motivation, knowledge, skill and perseverance. Common Investigations There are hundreds of tests and investigations to diagnose illness / disability. During your placement you will have the opportunity to prepare patients, observe investigations and care for them afterwards. The following are the most common investigations in which you are likely to be involved whilst on the ward. Make notes about any specific preparation, aftercare and what the test involves if you are able to go with the patient. Please ask to observe as many investigations as possible during your stay with us. Insertion of PEG MRI scan Abdominal Ultrasound Doppler Gastroscopy X-ray procedures CT scan Videofluroscopy Cardiac Echo TOE ECG Lumber puncture Ultrasound Scan Telemetry APL Sreen Medical Conditions and Rehabilitation Problems Throughout your placement you will be involved in caring for patients with a wide variety of medical and rehabilitation needs. Those listed below would be common on any medical/rehabilitation ward. Make notes about the nursing care including drug therapy if relevant. Stroke (CVA)/TIA (Stroke Clinical Nurse Specialist based on the ward) Ischaemic Heart Disease (IHD) Multiple Sclerosis Rheumatoid/Osteo Arthritis Chronic Obstructive Pulmonary Disease (COPD) Parkinson's disease MRSA/infectious diseases Dementia/Alzheimer's disease Chest infection/pneumonia If you are unsure about any of the above and their treatment, please ask someone for further information. Handover / Safety Briefing / PSAG Prior to commencement of the shift a Safety Briefing takes place at the nurses’ station, outlining a brief rundown of any identified or potential problems encountered by the previous shift. This briefing is given by the nurse in charge. This is for all staff members to listen to, prior to receiving the patient handover. We then split into two teams where a verbal handover is given to the nurse in charge of each of the teams, this is then relayed to other team members within the hour. Patient Safety At a Glance (PSAG), this is a board on the ward used by all MDT members and updated at least twice daily, by nursing staff or therapists. ‘ The use of visual management to show important patient information so that it can be updated regularly, seen at a glance and used effectively. The aim is to make patient information clear and easily understandable for all relevant disciplines.’ Things considered are; Patient status Expected date of discharge Next Actions…referrals Patient location on ward Waiting for… Ready for discharge Dietary status Risk assessments Responsible nurse/consultant Admissions to ward Transforming Care Our ,Ward Vision, within Transforming Care is; ‘To provide the individual with a high quality of care in a safe, clean environment where patients feel happy and well cared for – staff are happy to come to work, Pre and post aims for Transforming Care within the ward, can be seen on the story board on the unit. The Medical Staff With having two main specialities (Stroke & Haematology), we have specific consultants within these fields; Dr Bella Richards – Stroke Dr Chillcott – Haematology Dr Parry-Jones - Haematology Dr Lewis - Haematology Each consultant has a senior house officer working for them, along with staff grade doctors who are available for a more senior opinion. Weekly multidisciplinary meetings (MDM) are held in order to provide a holistic approach to the patient's care and future plans. In addition to the doctors, a nurse, physiotherapist, occupational therapist, social worker, dietician, speech and language therapist and occasionally a clinical psychologist are present at the meeting. If you want to bleep a doctor or anyone else, the bleep system is as follows: Dial 765 followed by the bleep number Then enter the ward extension number Wait for the recorded message to say that your paging request has been accepted and replace the handset The Ward Clerk Sue Evans is our ward clerk covering 4 days a week. The main role is to off load some of the administrative work from the nursing staff to enable us to spend more time with patients and relatives. Some examples of what is done: answering the telephone and making referrals booking ambulances admitting and discharging patients making out-patient appointments requesting and maintaining medical notes ordering supplies and equipment liaising with consultants' secretaries filing results in appropriate places Sue is a valuable resource and you may find it useful to spend some time with her during your placement to learn about administrative work that is required to ensure the ward runs smoothly. Sue has an excellent knowledge of the hospital and its various departments if you want to know where anything is. The Multidisciplinary Team (MDT) On the unit we work closely with other professionals in order to provide the optimum standard of patient care. We make referrals on a daily basis or when the relevant person is visiting the ward. You may wish to spend some time with one or more of the different disciplines in order to gain a holistic insight into rehabilitation / nursing care. Physiotherapists - present on the ward daily, they also hand over from the nursing staff every Monday morning to pick up any new referrals or problems. Physiotherapists rotate frequently so the best time to meet with them is when they are on the ward. Occupational Therapists - present on the ward daily. Occupational Therapists rotate frequently so the best time to meet with them is when they are on the ward. Speech and Language Therapists - visit the ward regularly and can be contacted in the SALT department. Dieticians - visit the ward regularly and can be contacted in the dietetics department. Social Workers - can be contacted in the social work department. There is a list of social workers that work outside the area i.e. Powys, Torfaen, and Blaenau Gwent etc. Pharmacists - visit the ward on a daily basis and can be contacted in the pharmacy. Stroke Specialist Nurse (CNS) – Based on the ward Monday – Friday, and also rotate to Tia clinic, in NHH Windsor Suite – Haematology Day unit, in NHH Rehab Assistants- Assists physio and occupational therapists Shift Times / Off Duty Nursing staff on the unit generally follow a 12 hour shift pattern, occasionally 6 hour shifts can also be worked. Day shift 0700hrs - 1930hrs Night shift 1900hrs - 0730hrs The E-Rostering system is used within the hospital, whereby requests for Off Duty can be made on the intranet by each staff member. (Not Students) Due to the fast pace and high intensity on the unit, students are not encouraged to work more than two consecutive 12 hour shifts. Often it is more conducive towards learning if students follow a 5 day week shift pattern. All students will be allocated a Main & Co. Mentor, and should aim to work at least 40% of shifts with the Main Mentor. If you have any queries or special requests, please liaise with either of your mentors or a senior member of the ward staff. Ward Layout During your first day you will be orientated to the ward layout, and all emergency systems. If you have any problems finding any equipment etc, please speak to any member of staff. Sickness If you are ill and unable to attend work it is essential that you contact the ward as soon as possible. You should also make yourself aware of the sickness policy for the trust. When you ring please ask to speak to the nurse in charge and tell them what the problem is and how long you anticipate being off work. You must contact the ward on a daily basis if you are unsure how long you will be sick. Uniform Whilst on duty on the ward it is important to remain professional at all times. The correct uniform must be worn with your name badge displayed, long hair should be tied back and jewellery kept to a minimum. Mobile phones are not permitted in the clinical area. Uniforms are not to worn into work, changing facilities and locker is provided on the unit. Manual Handling Your manual handling specialists on the ward are SN.Sian Langdon and AN Eva Kozik. There are a number of manual handing aids on the ward to assist with the transferring and moving of patients such as slide sheets and hoists, therefore uncluttered wards are essential. All nursing staff are trained in the correct manual handling techniques and it is important that you adopt the same methods and precautions to avoid injuring yourself or others. If you have any questions or concerns regarding manual handling please ask. Cardiac Arrest In the event of a cardiac arrest you may be asked to call the crash team. This is done by dialling 2222. Switchboard will answer the phone immediately. You will need to tell them clearly where the cardiac arrest is. Do not replace the receiver until the switchboard has repeated the ward back to you. The emergency trolley, defibrillator and suction equipment are checked every night, and are located in the treatment room; these will be shown to you on your ward orientation. You should make yourself familiar with this equipment. You are responsible to attend an annual CPR/ BLS training session. Fire Safety In the event of finding a fire, you should raise the alarm by shouting and breaking the 'break glass' points. You should familiarise yourself with the Health Board policy on Fire Safety and attend an annual lecture. Abbreviations During your placement and training you will come across numerous abbreviations in handover, written work and everyday use. Here are some of the most common used: AF Arterial Fibrillation (cardiac Arrhythmia) BD Twice daily (frequency of tablets, observations or BMs) BM Blood sugar monitoring BNF British National Formulary (drug Bible) CBD Closed bag drainage (used in catheterisation) CCF Congestive cardiac failure (right sided heart failure) CD Clostridium Difficile (infected stools) COPD Chronic Obstructive Pulmonary Disease CPR Cardio-pulmonary resuscitation CSU Catheter specimen of urine CT Computerised tomography CVA Cerebro-vascular accident CVP Central venous pressure (pressure in right atrium) DVT Deep vein thrombosis (blood clot in the leg) ECG Electro-cardiogram (tracing of heart rhythm) ERCP Endoscopic retrograde cholangio-pancreatography FOB Faecal occult blood (stool sample to detect bleeding on the bowel) IHD Ischaemic heart disease IM INR IV IDDM LFT Intra-muscular (injecting into the muscle) International normalised ratio (blood test for patients on warfarin) Intra-venous (injecting into the vein) Insulin dependant diabetic Liver function tests (blood tests) LP LVF MI MRI MRSA MSU NAD NG NIDDM OD OT PE PEG PRN PT QDS SAH SALT SDH SVT SW TDS TIA TTO USS VF Lumbar puncture Left ventricular failure (left sided heart failure) Myocardial infarction (heart attack) Magnetic resonance imaging (scan) Multi resistant staphylococcus Mid stream urine (specimen) No abnormalities detected Naso-gastric (feeding tube) Non insulin dependant diabetic (controlled on tablets or diet) Once daily (frequency of tablets, observations etc) Occupational Therapist Pulmonary embolus (clot on lung) Percutaneous endoscopic gastrostomy 'pro re nata' (Latin for 'as required') Physiotherapist Four times a day Sub-arachnoid haemorrhage (bleed in the brain) Speech and Language Therapist Sub-dural haemorrhage (bleed in the brain) Supra-ventricular tachycardia (fatal heart rhythm) Social worker Three times a day Transient ischaemic attack (a small stroke) Tablets to take out (patient's discharge medication) Ultrasound scan Ventricular fibrillation (cardiac arrthymia) GLOSSARY AMAUROSIS FUGAX (TRANSIENT MONOCULAR BLINDNESS): a sudden blindness, often like a black shutter coming down affecting one eye. This is usually the result of problems with the circulation to the brain and eye and is a sort of mini-stroke affecting the eye. Needs to be assessed by a doctor. ANEURYSM: an abnormal weak area of blood vessel wall prone to bursting (a common cause of a subarachnoid haemorrhage). APOPLEXY: a very old term for stroke. ARTERY: a blood vessel usually carrying blood pumped from the heart to parts of the body. This is the higher pressure part of the blood supply system. ASPIRIN: a well known drug that thins the blood and prevents clotting. Used to treat patients with stroke. ATHEROSCLEROSIS: the medical condition that leads to the furring up and blockage of blood vessels. This damage to the blood vessels is often a source of blood clots, leading to strokes and heart attacks. ATHEROTHROMBOSIS: the condition of abnormal blood clots forming on damaged blood vessels (atherosclerosis). ATRIAL FIBRILLATION (AF): an abnormal heart condition where the heart beats irregularly, often causing palpitations; it can lead to strokes caused by abnormal blood clots formed in the heart. CAROTID ARTERIES: the two main blood vessels in the front of the neck which make up two of the four main blood vessels supplying the brain. CEREBROVASCULAR ACCIDENT (CVA): an old term for stroke. CEREBRAL HEMISPHERE: the main right and left parts of the brain are called the cerebral hemispheres. The left hemisphere usually controls the right side of the body. The right hemisphere usually controls the left side of the body. Language is controlled by the left hemisphere in right-handed people and also in about 50 per cent of left-handed people. CLOPIDOGREL: a blood-thinning agent that can help prevent stroke. CT (COMPUTED TOMOGRAPHY) SCANNER: the x-ray machine that can produce detailed pictures of the body. A brain CT scan can show the cause of stroke and exclude abnormal bleeding in the brain. DIABETES: a common condition that causes abnormally high levels of sugar in the body. Often need treatment by diet, special pills or insulin. DIPYRIDAMOLE: a blood-thinning agent that can help prevent stroke. DISSECTION: an abnormal tear in the blood vessel wall that can cause strokes, especially if the blood vessel has been damaged by a sudden bang or pressure over the blood vessel. This can be a cause of a stroke after attempting strangulation or a sports injury. DYSARTHRIA: a problem of producing the sounds of speech. This may merely be a slurring of speech but in severe cases can mean a total loss of speech (anarthria). DYSPHASIA: a problem of language production. Mild forms can cause word-finding difficulties, moderate dysphasia causes muddled words and phrases, and severe cases result in no language at all (aphasia). The term is also used for difficulty in understanding speech. ECHOCARDIOGRAPHY: a detailed scan of the heart using ultrasound. A special probe is placed on the chest wall and the sound waves can be analysed to form pictures of the heart beating. ELECTROCARDIOGRAM (ECG): a recording of the electrical activity of the heart by attaching wires on the arms, chest wall and legs. A very common test after a stroke as heart disease is common in people with stroke. HAEMORRHAGE: an escape of blood (abnormal bleed). HEMIANOPIA: a loss of vision in part of the visual field. For example, some people with large strokes affecting the left side of the brain lose the ability to see to the right. HEMI PARESIS: a weakness affecting the arm and leg on the same side of the body as a result of problems with the brain or spinal cord (often abbreviated to ‘hemi’ by patients and medical staff). INDAPAMIDE: a mild diuretic (water tablet) to lower blood pressure. INFARCT: permanent damage to body tissue (tissue death). A cerebral infarct is when part of the brain is irreversibly damaged by a blocked blood vessel INTRAVENOUS: the method of giving fluids straight into the blood supply system of the body. The veins are the low-pressure blood vessels and are relatively easy to use. ISCHAEMIC: tissue starved of a normal blood supply as a result of a blocked or narrowed blood vessel. Often leads to permanent damage, for example, a stroke in the brain. MAGNETIC RESONANCE IMAGING (MRI): a sophisticated scanning technique that uses a powerful magnet (rather than x-rays) and computer to produce detailed pictures of the body. People with metal implants (for example, an intracranial aneurysm clip or a pacemaker) cannot be scanned because the magnetic field is so powerful that it can dislodge the metal. MIGRAINE: a common medical condition characterised by flashing lights, feeling sick, a throbbing one-sided headache and an overwhelming need to lie down in a darkened room. Can be very mild or very severe. Very occasionally a severe attack can cause a stroke. OCCUPATIONAL THERAPIST: a therapist who helps people do everyday activities such as wash, dress, eat, make meals and use the toilet. OESTROGEN: a female hormone, used in the oral contraceptive pill. PERINDOPRIL: a commonly used blood pressure-lowering tablet, which is also used to treat heart failure. PHYSIOTHERAPIST: a therapist who uses movement and exercises to help people recover from stroke and other disabling conditions. PRIMARY INTRACEREBRAL HAEMORRHAGE: an abnormal collection of blood in the brain resulting from a burst blood vessel (artery). The second most common cause of stroke. PULMONARY EMBOLISM: a blood clot which travels to the lung and damages part of it. This can be a complication of stroke, especially if there has been a leg thrombosis. Potentially very serious and can result in death. RANDOMISED: the method of allocating clinical trial treatment in medical research. This makes sure that the doctor and patient do not cheat and choose the treatment themselves. SEIZURES: an electrical storm in the brain often causing loss of consciousness, abnormal muscle twitching, abnormal behaviour and a short period of excessive sleepiness (or varying combinations of the above). Epilepsy is the term given to a condition with frequent attacks. A single attack can occur with the onset of stroke and stroke is the most common cause of epilepsy in older people. SIMVASTATIN: a tablet form of the ‘statin’ group of cholesterol-lowering pills used to treat patients with heart attacks and strokes. SOCIAL WORKER: a member of the stroke team with expertise in financial matters (for example, benefits), local services to care for patients after hospital discharge (for example, home care and meals on wheels), and assessing whether people need continuing care in residential or nursing homes. In the UK, social workers are usually employed by the local council, although they are often based within the NHS hospital. SPEECH AND LANGUAGE THERAPIST: a member of the stroke team with special expertise in assessing communication and language. They have also developed a very important role in assessing the safety of the swallow mechanism and help to advise the nursing team on the best feeding methods for patients with stroke. STATINS: a class of cholesterol-lowering pills, which will be increasingly used to treat patients with stroke. STROKE: a sudden onset of loss of neurological function (for example, weakness affecting arm and leg, speech problem), with symptoms that last more than 24 hours, resulting from a problem with the blood supply to the brain. SUBCUTANEOUS: the method of giving fluids into the body by allowing the body to absorb the fluid from under the skin. A really useful way of giving people extra fluids with few side effects. THROMBOLYTIC THERAPY: powerful blood clot-dissolving treatment. The main treatment for heart attacks and a promising treatment for some strokes. Unfortunately, it can cause severe bleeding in some people and more research will be needed to check that this type of treatment should be used. Recombinant tissue plasminogen activator (rtPA) and streptokinase are the most commonly used thrombolytic agents in the UK. TICLOPIDINE: a blood-thinning agent which can prevent stroke. It is only rarely used in the UK because of important side effects on the blood. Needs to be carefully monitored with frequent blood tests. TRANSIENT ISCHAEMIC ATTACK (TIA): a mini-stroke with symptoms that fully recover in less than 24 hours (often recover within seconds or minutes). Can be a warning that a more severe stroke is about to happen. Should be assessed by a doctor. TRANSIENT MONOCULAR BLINDNESS: see Amaurosis fugax. TRANSOESOPHAGEAL ECHOCARDIOGRAPHY (TOE): a special heart scan by using sound waves from a tube placed in the oesophagus (gullet). Needs a skilled person to place the tube in the correct place and the patient usually requires a mild sedative or throat spray. WARFARIN: a commonly used tablet to thin the blood. Very useful for preventing strokes but can cause abnormal bleeding.