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:
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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:
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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
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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:
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Covering coughs and sneezes
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Insuring immunizations are up to date
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Using PPE’s (gloves, aprons etc)
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Using alcohol gels
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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.
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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.
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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.
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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.
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Grade
3: full thickness skin loss involving damage to or necrosis of
subcutaneous tissue.
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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?