Cardiff and Vale University Health Board Unscheduled Care Directorate Student Nurse Information Pack MEAU – University Hospital Llandough WELCOME Welcome to your placement at Llandough hospital MEAU. This pack has been put together to provide you with information for your placement with us. The following information will be provided to you on your first day with us. Mentor Name: ------------------------------------------------------Co mentor: ---------------------------------------------------------Link Tutor: Jacqui Rattray Address: Cardiff University TDS Email:rattrayja@cf.ac.uk Direct Telephone number: 029 20687823 Clinical teacher: janet keggie 02920687661 (Ty Dewi Sant, UHW) Mobile 07974579716 Lead mentor Rachael Maiden 02920715041 (office) 02920715125 (main desk) What you can expect from us • You will receive an induction into MEAU to ensure you are familiar with our environment and are able to practice safely • You will discuss your learning needs and outcomes at the beginning of the placement • We will provide an environment conducive to meeting identified individual student learning needs which is also safe and healthy. • During your placement you will be allocated a mentor to work alongside. The mentor will be a qualified practitioner who has undertaken the mentorship training, who will assist and support you during your clinical work. • Your mentor will assess your performance against your course learning outcomes, and provide feedback to help you develop your skills. • You will receive supervision during your clinical practice. • You will be a valued member of the multidisciplinary team during your placement, and can expect support from all your colleagues • We will listen to your feedback about your placement and will respond to any issues raised sensitively What we expect from you • We expect you to arrive on time for planned shifts and any other activity identified by the Mentor or delegated supervisor • We expect you to ensure your Mentor is aware of your learning outcomes for the placement and specific learning needs • We expect you to act in a professional manner. • We expect you to dress in accordance with your College / University uniform policy, and also in accordance with the Cardiff and Vale UHB uniform policy. • You should inform the unit and the university if you are unwell and not able to attend your placement, and tell us when it is likely you will return. • We expect you to maintain and respect confidentiality at all times. This applies to patients, their records and discussions between the student and the Mentor, this also includes the use of social network sites as Cardiff and vale UHB policy. We want you to enjoy the placement and get the best outcomes that you can, however if you have any issues regarding your placement please discuss this with your mentors or lead mentor. If this is not possible you should contact your link tutor. Also we want to learn from you so please share all your new knowledge that you’ve already learnt with us. Orientation to the Unit Please be aware on your arrival of the following points ● Fire exits/ Assembly points/ Fire equipment/ Fire alarms ● Location of Policies and Procedures (Accessible through the intranet) ● Role of security staff ● Placement of all emergency equipment and crash trolley What is MEAU? MEAU consists of three different clinical areas; a trolley bay which has 12 trolleys, 6 of which have cardiac monitors, an ambulatory waiting area which consists of a nurse triage room and four examining rooms for the doctors and finally a crash area which has two individual crash rooms both with cardiac monitoring. We have a large team of staff, made up of Band 7, Band 6, Band 5, Band 3 and Band 2 health care assistants and a Doctors assistant. The ward manager is Ceri Richards –Taylor and the Clinical Lead nurse is Julia Evans. We also have an Acute Care Physician- Dr Osman, the consultancy role is there to facilitate early discharges or transfers to the appropriate ward and they review patients in MEAU from the hours of 9-5 Monday- Friday. How it works MEAU receives all GP referrals from the west of Cardiff, Penarth and Barry. We also receive all medical 999 calls from this area. MEAU does not accept any patients, in cardiac arrest or needing potential surgical input ie abdominal pain, PR bleeding etc and these patients would be diverted to UHW. We also accept all patients who have taken an overdose, as long as there GCS (Glasgow Coma Scale) is above 8. If there is a bed available patients will go up to Gwenwyn, a specialist poisons ward, if no bed is available the patient can stay on MEAU but only if there is capacity ie if the waiting area is empty and trolley spaces are available, otherwise they will be diverted to UHW. We are a fast moving area, most patients staying less than 24 hours. Patients who arrive in the department Monday to Friday between 9am and 20.00pm are either seen by an Acute Care Physician or by the consultant on call at 20.00pm. Those who arrive after 20.00pm are seen at 9am the following day by the consultant on call; however some patients are discharged by the registrar on call. At the weekend there are just the two consultancy ward rounds at 9am and 20.00pm. Shift Times We work 12 ½ hour shifts Day shift: 7am - 19.30pm Night shift: 19.00pm – 7.30am Mid shift : 10.30 – 23.00 Twilight : 1330- 0200 We ask that you try to work a variety of these shifts so that you can see all aspects of the patients journey. Mentors A mentor and a co-mentor is allocated to you before your placement commences. There is a student board where this will be posted, along with other useful contact numbers and details. You should aim to work alongside your mentor or co-mentor at least 50% of the time; however we are aware that this is not always possible, in such circumstances supervision and support will be given by another qualified member of staff. Main Objective Our aim is to provide you with enough experience for you to be able to discuss the admission process and triage of patients. To develop your knowledge of a variety of emergency medical conditions, the treatments and under supervision provide the nursing care required. Useful Numbers More numbers can be found on the student notice board MEAU 02920 71 5215 or Ext. 5215 Ext. 5216 Clinical Teacher – Janet Keggie Lead mentor - Rachael Maiden Sickness and Absence If you are unable to attend work when expected for any reason, please ring and inform the nurse in charge of your absence. This should be done at least four hours prior to your shift starting. You must also report absent to the school of nursing. If you are making up hours, please be aware that the trust does not allow you to exceed 50 hours in any week period. Learning opportunities MEAU can provide you with a variety of learning opportunities; these can be discussed on a more personal level with your mentor. You can also arrange to spend time on other wards or with other professionals. For example; nurse practitioners, Gwenwyn ward or the Enhanced care unit. Please highlight your preferences to your mentor, who will aid you in organising this. Emergency Numbers Cardiac Arrest ……………….2222 In the event of a cardiac arrest you will need to dial the above number, stating clearly the location eg Cardiac arrest MEAU Fire…………………….3333 In the event of a fire please call the above number stating clearly your location. Using the bleep system When you wish to bleep somebody, dial 81 and listen for the tone, then dial the bleep number and again listen for the tone, then dial your extension number followed by #, finally replace the receiver and wait for your reply. The Admission Process On arrival patients are triaged using the Manchester Triage System. Depending upon their condition on arrival and recommendations from ambulance staff, patients are allocated either to the trolley bay, crash room or waiting area. This is carried out by the shift co-ordinator (nurse in charge). Patients are then admitted by a nurse, there is an admission pack ready made with all of the documentation needed within. Firstly an over view of what has bought the patient into hospital is taken and recorded. This information can be gained from a variety of sources; GP letter, ambulance crew, the patient and the next of kin. Details of there medical history, there medication and if they are allergic to any drugs is also recorded. Alongside this baseline observations are recorded, this includes; BP, pulse, O2 saturations, respirations, temperature, BM, peak flow and an ECG. These are all recorded in the admission pack on the front sheet (see example). The assessment is recorded in the form of SBAR; in conjunction with the Manchester Triage System. S: Situation – what is the patients problem/ what has happened to bring them into hospital. . For example;increased breathlessness, coughing especially when walking/ having chest pains or increased confusion. Background – what is the history ? has this happened before ? what was pt like prior to the event. A: Assessment What you have found, which will include interpretation of vital signs For example heart rate 120 RR 40 . what is the triage? , what is the NEWS. R- Recommendations – what will you do next. For example; Bloods, 02, xray refer to medics. Details are also taken of the patients NOK (next of kin) and there GP. The Pat-e-Bac and Waterlow assessment tools should be completed on every admission, if the patient is at risk of falls or nutritionally compromised then those risk assessments should also be completed. Every patient must also have an identity wrist band and sign the property disclaimer form, if they are able to. Once the patient has been admitted, assessed and triaged by a nurse then these notes are placed with the appropriate triage in the racking system in the waiting area. The patient then waits to be assessed by a doctor, who will make a decision about there treatment, admission or discharge. It is important to explain the process to the patient and their relatives as this can be an anxious time. When the unit is busy, patients who are not a high priority may wait a long time to be seen by a doctor, during this time if there condition changes, more observations should be taken and recorded and the patient should be re-triaged. Your mentor will go through this process in more detail and when you feel more comfortable with this, you may participate in admitting patients under supervision. What is Triage? The word ‘triage’ came from the French word ‘to sort’. It was first used in battle to identify soldiers who were well enough to return to battle in around 1792, by Napoleon’s Imperial Guard. It was first used in the UK by American Army Medics in Harrow train crash 1952. However it was not introduced extensively in UK emergency departments until 1980’s. The idea of triage is for it to be a brief focused clinical assessment. It is a dynamic process, as the patient’s condition can change rapidly, therefore the triage system may need to be repeated several times. When recording patient’s vital signs onto the observation chart you will see that Early Warning Score (EWS) is used. This scoring system identifies how often a patient should have their observations recorded and who should be notified about the patients observations depending on what score they have. This should be used along with the triage system to ensure patients are triaged appropriately. There are a number of different triage systems adopted by different emergency departments all over the UK. Here in MEAU we use the Manchester Triage System. The idea of this system is to focused on airway, breathing and circulatory problems. It aids nursing staff in identifying the most unwell patients and defines the most appropriate area of care. It uses a flow chart layout, firstly you must decide what is the patients presenting problem i.e. Chest pain; shortness of breath or generally unwell. You can then select the appropriate flow diagram. The triage folder is red and is located on the reception desk in the waiting area and on the nurse’s station in trolley bay. There are waiting times identified for the triage code and these are Red: should be seen immediately Orange: should be seen within 10 minutes Yellow: should be seen within 60 minutes Green: should be seen within 120 minutes Importance of Vital Signs What are vital signs? • Respiratory rate and oxygen saturations • Heart rate (pulse) • Blood pressure • Temperature • Blood glucose monitoring ● Patients conscious level Respirations must be recorded on every patient as this is one observation commonly not recorded yet it is one of the most important. What is ‘normal’? • Respiratory rate between 10-20 breaths per minute • Oxygen saturations above 92% on Air (may be lower in chronic chest patients) • Heart rate between 60-100 beats per minute • Blood pressure systolic above 100 mmHG • Temperature between 36-38 • Blood sugar between 4- 7 mmol Airway, breathing & circulation are required to maintain life. A problem with airway, breathing or circulation can lead to vital organ failure which in turn may lead to cardio-respiratory arrest. However it is important to remember that 80% of patients that suffer cardiac arrest have shown early warning signs which may have been missed. There is a wide range of medical conditions can place patients at risk. Regular vital signs monitoring will help to identify potential problems and changes in the patient’s condition. This will aid the recognition of an unwell patient. Recording of vital signs on the observation chart clearly shows patients who have abnormal vital signs. It is critical to report any changes in vital signs, vital signs that fall within the red zone on the observation chart to a qualified nurse. These patients may require medical intervention. This can be a variety of things for example being triaged again, moved into a more appropriate area or seen by a doctor immediately. Early recognition of patients who are becoming unwell saves lives. Airway Airway obstruction can be caused by the tongue, blood, vomit, foreign body, central nervous system depression (drop in GCS) trauma, infection, inflammation and laryngospasm. The signs of an obstructed air are; • Difficulty breathing, distressed, choking • Shortness of breath • Wheeze, gurgling • Changes in Colour • Altered level of consciousness It is important to get help immediately. Open the airway using a head-tilt and chin lift manoeuvre, suction may be needed and the patient will require high levels of care and further investigation. Breathing Inadequate breathing can be caused by decreased respiratory effort or drive and also by a pulmonary disorder (i.e. PE, pneumonia). The signs of inadequate breathing are; • Short of breath • Strenuous breathing • Use of accessory muscles • Tachypnoea (resp rate >30rpm) or resp rate <10rpm • Cyanosis (blue lips, blue nailbeds) • Oxygen saturations <90% If a patient is struggling to breath, get help immediately. Give the patient high flow oxygen. They will need further treatments and investigations. Circulation Signs and symptoms of circulatory/cardiac problems are; • Chest pain, palpitations • Short of breath • Heart rate >100bpm (or <60bpm) • Weak, thready pulse • Systolic blood pressure <90mmHg • Urine output <30mls/hr • Cold, clammy skin There are other signs that you should look out for which could mean a patient is becoming unwell. If they are confused, irritable or have a change in there conscious level (GCS) these symptoms can be caused by numerous things for example it may mean they have a lack of oxygen or they are having a hypoglycaemic attack. It is important to record all vital signs and inform a qualified nurse of your concerns. Understanding ECG’s Every patient that comes into MEAU will have an ECG taken along with all of there other vital signs. If a patient has presented with chest pain or a history of chest pain it is important that they have an ECG within 10 minutes and this is seen and signed by the SpR on call. When looking at an ECG, you can identify what the persons heart rate is and if the rhythm is regular or irregular and if there are any changes in the ST segment which can be indicative of a heart attack and ischaemic heart disease. Also look at the P wave make sure that it is present, if it is a normal shape, if it precedes the QRS and if the P-R interval is normal. Finally you should be able to see if the QRS complex is a normal size and shape. Useful Calculations 1 small square = 0.04 seconds (1mm) PR interval should be no more than 5 small squares and no less than 3 (0.12-0.20 seconds) QRS should be no less than 2 small squares and no more than 3 (0.08 -0.12 seconds) QT should be between 8-10 small squares (0.33-0.43 seconds) Normal Sinus node Rhythm. The above is normal sinus rhythm. The impulse begins in the SA node in the atrium and follows the normal path of conduction. Rate: 60-100bpm Rhythm: regular P waves: upright and proceed QRS complex P-R interval: normal QRS complex: normal Sinus Bradycardia The above is sinus bradycardia, the impulse still begins in the SA node but the rate is slower. Rate: below 60bpm Rhythm: regular P waves: normal P-R interval: normal QRS complex: normal Sinus tachycardia Above is sinus tachycardia. The impulse still originates in the SA node but the rate is faster than normal sinus rhythm and you may not see a P wave because it is buried by the T wave. Rate: 100-180bpm Rhythm: regular P waves: normal – or hid by the T wave P-R interval: normal QRS complex: normal Atrial Fibrillation (AF) The above is atrial fibrillation. In AF the heart muscle of the atria ‘quiver’. The impulses that are normally generated at the SA node become overwhelmed by the electrical acivity in the atria (upper chambers of the heart) leading to irregular impulses to the ventricles which creates a heartbeat. Rate: Atrial 360/ventricular 60-180bpm Rhythm: totally irregular P waves: absent P-R interval: can not identify QRS: usually normal Ventricular Fibrillation (VF) Above is VF. With a patient in cardiac arrest this is shockable rhythm. The impulse is originating in the ventricles, it is uncoordinated and very fast. Rate: in excess of 300bpm Rhythm: irregular P wave: unrecognisable P-R interval: absent QRS complex: absent Ventricular Tachycardia (VT) The above is VT. If patient is in this rhythm and has no pulse then the patient can be shocked (pulseless VT). The impulse begins from the ventricles, a series of 3 or 4 beats occur in rapid succession. Rate: in excess of 150bpm Rhythm: regular P wave: unrecognisable P-R interval: absent QRS complex: greater than 5 small squ Asystole Above is asystole. There is no cardiac output, there is no rate or rhythm. On a cardiac monitor it is flat line, or slightly wavy line. It is important to ensure that all leads and monitors and correctly connected. ST elevation MI Note the elevation in the ST segment in leads v1-v6 and avl, and ST depression in ii, iii, and avf. Understanding sepsis Sepsis can be a common condition that is presented to the assessment unit and , is potentially life threatening, so its important that symptoms are recognised and acted upon quickly. Sepsis spreads quickly causing inflammation and swelling and possible blood clotting. It is estimated in the UK that approximately 100,000 are admitted to hospital with sepsis, with around 37,000 patients dying of the condition. Early symptoms of sepsis usually develop quickly and can include: Temperature - < 36 or >38.3 °c Heart rate >90 bpm Respiratory rate >20/min WCC - <4 or >12x10L Altered mental state Glucose >7.7mmol/l (if patient not diabetic ) If patient has two or more symptoms and signs of infection think sepsis and act quickly In some cases, symptoms of more severe sepsis or septic shock (when the blood pressure drops to a dangerously low level) develop soon after. These can include: feeling dizzy or faint confusion or disorientation nausea and vomiting cold, clammy and pale or mottled skin If patients are developing these signs inform medical team straight away Treatment high flow o2 take blood cultures will need IV antibiotics IV fluids Check bloods Hourly urine monitoring Hourly observations Early detection can save lives Infection control Spread of infections, can cost lives and us as health professionals have a duty to help prevent the spread of them. We must all do our bit to help the spread. Correct hand washing technique is the best way to help the spread of infection. Other steps include: Covering coughs and sneezes Insuring immunizations are up to date Using PPE’s (gloves, aprons etc) Using alcohol gels Following hospital guidelines when dealing with blood or contaminated items Ensuring you are BBE (bare below elbow )at all times, and adhere to the uniform policy. Cleaning commodes after ever patient MRSA swabs for patients that meet the criteria. If you suspect a patient might be infectious (i.e. diarrhoea) inform the nurse in charge immediately. Transferring Patients Once a patient has been seen by a Consultant or by a registrar by night, the patient is able to be transferred to the appropriate ward. The patient would have been defined to a specific medical area on the ward round, and this will have been passed over to the patient access team by the nurse in charge. Patient access will then contact the nurse in charge on MEAU with allocated beds for the patients. Prior to transferring the patient the property disclaimer or property list should be completed, a set of observations, waterlow and pat-e-bac and patients notes updated. DVT patients During normal working hours the patient should be sent to the DVT clinic in UHW where they will conduct a full leg scan, as long as there are no other underlying problems. However out of hours the patient will be referred to us. If the doctor believes there to be a DVT the patient will be given clexane till the next appropriate day that we can refer to the clinic where they will take over their care. Patients have to be independent to attend this clinic, if not they stay under our care until a scan is preformed. Day returners At the reception desk we keep a diary so that we can see daily who is to return to MEAU for treatment. We have day returners so that patients do not have stay in hospital if it is not clinically needed but still need observing. This may included patients returning for clexane, dopplers, ct scans, monitoring INR levels etc. Sometimes the consultant may want to see them one more time to check that things have returned to normal after a few days, and check blood pressure, ecg or bloods again. This book is kept behind the desk and all referrals must go through the nurse in charge so that we have a suitable number returning daily. Discharging Patients If a patient is discharged from the unit and requires medications to go home with, the prescription will be sent down to pharmacy between the hours of 9 – 5pm, or if they are mobile they can take a prescription to pharmacy themselves, this applies Monday to Friday and 9 – midday on Saturday. If a patient is discharged out of hours MEAU does have a TTH cupboard with a small supply of medication. It is essential to remember that on discharge the yellow copy of the TTH is given to the patient for their GP. Some patients may be asked to return to MEAU the following day for tests and these patients should be placed in the day returner book which is situated in the waiting area on the reception desk. Pressure area care. In MEAU patients can remain on trolleys for long periods. Pressure area care is essential in order to prevent the development of pressure ulcers. In the UK pressure sores cost the NHS £1.4 – £2.1 Billion a year. This is 4% of NHS expenditure. Having a pressure sores significantly increases patients stay and risk of infections. Pressure sores are damaged skin and underlying tissue. They are caused by pressure, shearing and friction. The risk factors for pressure sores are: • Immobility • Loss of sensation • Poor circulation • Moist Skin • Previous pressure ulcers • Poor dietary intake It is important that all patients have their Waterlow assessment completed on admission. Good manual handling techniques reduce the risk of shearing and friction when moving patients. In MEAU we have disposable slide sheets that must be used for any patient who needs repositioning. When repositioning patients it is important to assess their skin, especially areas at risk. If a patients at risk then they should be on the skin bundle chart. All trolleys should be fitted withy a repose mattress to help reduce the possibility or pressure sores forming. Please encourage patients to move themselves as much as possible to not only keep skin healthy but promote independence. Pressure sores are graded I to V according to there severity. Grade 1: non-blanching red skin, which is intact. Look for any discolouration of the skin, on individuals with darker skin, the skin may appear blue or purple. Grade 2: partial thickness skin loss involving epidermis, dermis, or both. This is superficial for example an abrasion or blister. Surrounding skin may be red or purple. Grade 3: full thickness skin loss involving damage to or necrosis of subcutaneous tissue. Grade 4: extensive destruction, tissue necrosis, or damage to muscle or bone. Extremely difficult to heal. If a patient has a pressure sore on admission please do the following the body map must be completed. medical photography of the sore A referral to the tissue viability nurse Please also complete an incident form in accordance with hospital policy. Abbreviations used in MEAU CPR cardiopulmonary resuscitation NFR not for resuscitation DNR do not resuscitate BP blood pressure o.d once daily or overdose b.d twice daily t.d.s three times daily q.d.s four times daily prn as required s/c sub-cutaneous i.m intramuscalar p.o oral p.r rectal s/l sublingual H.b haemoglobin N.O.F neck of femur T.L.C tender loving care UTI urinary tract infection SALT speech and language therapy OT occupational therapist PT physiotherapist SW social worker NG nasogastric CVA cerebral vascular accident TIA tans ischemic attack LVF left ventricular failure CCF congestive cardiac failure COAD chronic obstructive airways disease COPD chronic obstructive pulmonary disease CHD coronary heart disease ECG electrocardiogram CABG coronary artery bypass graft CIWA Clinical Institute Withdrawal Assessment for Alcohol. MI myocardial infarction NSTEMI non ST elevation myocardial infarction STEMI ST elevation myocardial infraction SOB shortness of breath LFT liver function test TFT thyroid function test DT’s delirium tremers MSU mid stream urine PFR peak flow recording Acopia unable to cope Student evaluation Please hand back at end of your placement Were you Allocated a mentor and co-mentor on arrival and did you have an initial interview with your mentor during your first week to discuss objectives Did you achieve your set objectives whilst on placement? Did you have the opportunity to visit other areas? And was this helpful Did you find Student information pack was useful? Would you like anything else included? What did you enjoy most about your placement? What would you improve about this placement?