SHARING GOOD PRACTICE
Placement name and organization
The Chest Pain
Royal United Hospital
Bath.
The learning tool we have devised is
A student learning Pack.
It is particularly useful for
New students and nursing staff who have little or no
cardiology experience. It allows an overview of
cardiology, our patients and their journey.
If you would like more information about this please contact
The Chest Pain Unit
01225-821901
We do not wish you to adapt or use this material
without consulting us first
.
Adapted from original version 2003, Sian Kerr 2005
Welcome to The Chest Pain Unit (CPU), we form part of the emergency directorate.
We are a nine bedded short stay chest pain assessment unit. We take patients
directly from the emergency directorate, after full assessment and having ruled out
cardiac factors we then send them to the appropriate ward or home, the length of
stay with us is meant to be 24 hours.
The aim of this booklet is to guide you through your placement offering you ideas of
what to see and who to spend time with, as well as being a work book for you to work
through during your time with us.
You will be given a main mentor who will be your assessor and two named associate
mentors to facilitate your time with us.
We hope you enjoy your placement with us!!!!
We work the following shift patterns:
Early: 07:00 – 15:00
Late: 13:30 – 21:30
Night: 21:00 – 07:30
During your time you will be rostered to work all of the above shifts, if you have any
requests please speak to the person doing the off duty. Your shifts will reflect that
of your mentors to optimise learning opportunity.
You will be continuously learning in both an informal way through literature, mentors,
learning pack, information boards and so on. There are also formal teaching sessions
with the emergency department every Friday at 14:00, you will be encouraged to
attend these.
We have links with the following areas, if you wish you can spend some time in/on:
The Coronary Care Unit (CCU)
The Cardiac Ward
The Cardiac centre
The Emergency department (ED)
The Medical Short Stay Unit (MSSU)
The Medical Admissions Unit (MAU)
We expect you to be familiar with the following:
Signature
Health and safety policy
Infection control policy
Manual handling
Fire policy
Hand washing procedure
Also in each area you work make yourself familiar with:
Duty arrangements
Staff sickness procedure
Visiting hours
Date
The Patient’s Journey
The Emergency Department

The Chest Pain Unit

Blood Test: Troponin T +/Exercise Tolerance Test (ETT) +/Echocardiogram (ECHO)



Home
Cardiac Ward
CCU


Home
This is a very simplified patient’s journey.
Home
A patient’s stay in the chest pain unit can be brief, however sometimes their stay in hospital is longer and they come into contact with a variety of people for various
investigations, here is a spidergram of a patient’s journey and those individuals a medical patient might come into contact with.
Ward Staff:
Ward Sister
Junior Sister/Charge Nurse
Staff Nurse
Health Care Assistant
Housekeepers
Consultants
(Senior) House Officers
Admission To Hospital
Hospital chaplain
Discharge Liaison
Rapid Emergency Assessment Care Team (REACT)
Bed Manager
Site Manager
Senior Nursing Roles:
Modern Matron
Head Of Nursing
Family & Carers
Community Staff:
General Practitioner (GP)
Practice Nurse
District Nurse
Pain Team
.
A Patient’s Care Journey
Diagnostic Tests:
X-ray
MRI Scans
CT Scan
USS
Blood Tests
ECHO
ECG
VQ Scan
Spirometry
Dopplers
ETT
Specialist Nurses:
Consultant Nurse Macmillan Nurse
Stoma Care
Dietician
Respiratory
Nutrition
Diabetic
Out Reach Team
Stroke Team
Cardiac Rehab
Cardiac Nurse Practitioner
Cardiac Rehab Nurse
Inter-Professional Team:
Physiotherapist
Occupational Therapist
Social Worker
Pharmacist
Medical Staff
Speech & Language
Dietician
Outpatient
In order to help you meet the objectives for this placement we have written some
learning outcomes using the four domains to assist.
Domain 1: Professional /ethical practice
Learning outcome 1.3
* How would you support the individual rights of a patient and those of a group
within the clinical setting, for example, consider:
 privacy and dignity
 confidentiality
 the use of cot sides
 the use of drug therapy in sedating a violent/aggressive patient
 the individual needs of the patient.
You should also consider:
 the NMC code of conduct
 Clinical governance
 patient’s advocacy
 acts of parliament (e.g. mental health act etc)
Write a small piece on one of the above issues and discuss it with your
assessor/mentor.
* When caring for a patient who comes from a different cultural/religious
background consider what the differences are and how this affects the nursing care
that they need. Write a care plan that the rest of the team can use when caring for
this patient.
Domain 2: Care Delivery
Learning outcome 2.3:
*
*
*
*
*
What referrals are involved in patient care?
How do you identify which patients need referring to members of the MDT?
Consider how you would refer patients to members of the MDT.
What documentation is used?
What tools are used to assess patients?
It is unlikely that you will have the opportunity to assess all the aspects that are
identified in this outcome. Therefore to facilitate you achieving this outcome you
can consider the following:
* Work with the appropriate link nurse and add to the resource file.
* Work in a different area, e.g. Accident and Emergency, where you will have
the opportunity to carry out the necessary assessment.
* Research how the assessment is performed in other areas, write a piece of
feedback that could be utilised in the resource file.
Learning outcome 2.4:
* Identify a patient for whom you would like to do a care study.
When you have chosen a suitable patient, consider the following
 Signs and symptoms of the patient
 How is the pain assessed and managed
 The treatment options
 Actual and potential problems and complications
 The goal of care – including rehab, physio, OT etc if appropriate
 Discharge information
 Health promotion
 Discharge destination
 Follow up appointments
When a full assessment of a patient has been complete, identify a nursing problem
that the individual has, create a care plan including planning implementing and
evaluating of the care. Consider the psychological and physical aspects of the
interventions/goals/treatment that the patient will undergo. Identify what sources
of knowledge you used to achieve this.
Upon completion present an aspect of the care study to a small group of staff.
Learning Outcome 2.5:
Not all of the competencies identified in this learning outcome can be achieved on
CPU, therefore, you might consider working with the relevant nurse specialist or
working in another area of the emergency directorate may give you the opportunity
to learn and be deemed competent.
Also working with the relevant link nurse, or researching a topic independently will
help you gain understanding and competency in the relevant areas.
Consider why skills are performed in a certain way, identify the relevant research.
Are there any ways in which to improve on the current practice, for example essence
of care groups and any matters arising from this. You could also critique existing
policies and identify areas in which they could be improved. Feedback your findings
to your mentor/assessor
Domain 3: Care Management
Learning Outcome 3.1
This learning outcome is all about risk management.
* On the unit identify three risks and ways in which the risk can be reduced and/or
eliminated.
1,
2,
3,
* Identify resources that assist you in delivering safe care to patients.
* The assessment of manual handling and pressure sore assessment should be
covered in your case study. Discuss these with your mentor/assessor.
Learning outcome 3.3
Identify the roles of others within the care team on the chest pain unit, identify
those who you wish to work with to gain an over view of their role and constraints.
Reflect upon this.
Learning outcome 3.4
During your placement you will be expected to look after your own patients under
supervision of your mentor, therefore you will be doing everything that is expected
of a qualified member of staff from accurate documentation and handover to
complicated drug calculations to problem solving.
Domain 4: personal/professional development
Learning outcome 4.2
Reflective practice is very important, you will be asked by your mentor how you will
plan your day and care for your patient, you will also be asked to feed back
throughout the day and at the end of the shift how everything has gone, and ways in
which you could improve. You can use any of the reflective tools for this. We also
encourage you to reflect on your own and in your work based learning days with your
peers, on a weekly basis you will be asked to reflect on your week. You can use a
recognized model of reflection for this or alternatively you can adapt your own.
This will then be fed back to your mentor.
The Chest Pain Unit
Whilst you are with us you will develop other competencies. By the end of your
placement you will be able to demonstrate the significance of observations on
patient care.
To help achieve this utilise the table below:
Observation
Respirations
Temperature
Pulse
O2 Saturations
Blood Pressure
Fluid Balance
Normal
Parameters
Reasons For &
Signs &
Symptoms Of
Low Readings
Reasons For &
Signs & Symptoms
Of High Readings
Rationale For
Performing
Observation
By the end of your placement you will also develop competencies in:
 Using bedside monitors including the use of dinamap
Pulse oximetry
Cardiac monitoring
 Using all documentation
 Handing over patients to colleagues
 Participating in admitting patients
 Participating in transfer of patients to other wards
 Caring for a patient with unstable angina
 Referring patients to other members of MDT
 Assessing patients pressure areas
 Planning care
 Procedure for obtaining patient’s notes and x-rays
 Procedure for self discharge
 Using thermometers
 Understanding the principles and practicalities of blood glucose monitoring
 Performing urinalysis
 Collecting a specimen of urine
sputum
stool
 Preparing a bed space for a patient
 Observing cannula for signs of infection
 Performing ECG’s
The list goes on.
Taking a 12 Lead ECG, the student will demonstrate:
 the ability to accurately and safely perform a 12 lead ECG.
 Understand the principles behind performing a twelve lead ECG
You will be able to:
Rationale
explain why it is necessary
to take an ECG



to establish the rhythm
to establish if pain is cardiac in origin
to provide clinical evidence for diagnostic
purposes
explain when an ECG should
be taken





on admission
when having chest pain
if condition deteriorates/changes
pre and post thrombolysis
routine morning ECG (day 1-3)
explain to the patient the
task, why it is being taken
and gain verbal consent

must legally obtain informed consent
help the patient to the
correct position in a safe
manner


aware of safe manual handling techniques
ensures optimal reading
clean and prepare the skin

ensures good contact between skin and contact =
less electrical artifact
apply the 10 electrodes and
leads in the correct place

to ensure correct reading from both vertical and
horizontal planes
minimize electrical artifact


check lead placement
ensures they are not pulling or lying over each
other
asks the patient to relax and lie motionless

check calibration

correctly label the ECG and
file in notes
Show the ECG to someone
competent at ECG
interpretation

to enable interpretation using a standard
recording
useless without a name, date and time
Achieved
In order to be safe and competent when administering drugs, knowledge of the
different drugs and various routes is needed, use the following tables to help
Drug Group
Examples
Routes
Effect
Side Effects
Diuretics
Antihypertensives
Anticoagulants
Beta Blockers
Statins
Analgesics
Anti-emetics
Antibiotics
Nitrates
Drug Route
IM
IV
SC
Pros
Cons
Example
Other things to consider when dealing with patient’s medications:
 What checks should you undertake prior to administering any drug to any
patient?

What sources can you use to obtain information about drugs?

Why are some drugs locked away and signed out in a book?

Which drugs are they?

Explain the role of the student nurse in checking and administering medication
in each of the following:

-
Oral administration
-
Intravenous drugs
-
Controlled drugs
-
Blood Transfusion
What knowledge did you use to achieve this objective?
To assist you build your knowledge of infections, consider:
What is infection and what are the signs and symptoms?

What is colonization?

What is septicaemia?

Discuss the route of transmission and the port of entry of infection?

How can the transmission of infection be prevented?

Explain what you understand by the term MRSA and describe the management
of patient care.
Take one area you have seen on the ward where infection control can be improved
and look at it in greater depth. How can this be implemented in practice?
QUESTIONS
Never be afraid to ask questions
Here are some for you:
Anatomy and Physiology

Describe the position and size of the heart in the body

Name the layers of the heart wall and describe their purpose

Describe the circulation and blood flow through the heart

Describe the mechanism which transfers blood from the atria to the ventricles

Describe the purpose of the valves in the heart

Describe the purpose of the papillary muscles
The Heart

Label the diagram below:
The Conduction system

Label the diagram below:

What properties does the tissue in the conduction system have?

Describe the pathway of an electrical impulse through the heart in normal
sinus rhythm

Describe the representation of the P, QRS and T waves

What does each millimetre on the ECG paper represent?

Identify a patient with an arrhythmia. What is the rhythm? What is your
understanding of this arrhythmia. What is the nursing care for this patient?
Coronary Circulation
Draw and label this diagram with the:
Right coronary artery
Left coronary artery
Circumflex coronary artery

Describe the purpose of the coronary arteries

Which coronary artery supplies the sino atrial node?

Which coronary artery supplies the atrio ventricular node?

Which coronary artery supplies the inferior wall, anterior wall and posterior wall
of the heart?

How does knowledge of which artery is blocked affect our understanding of
myocardial infarction?
Coronary Heart Disease

What is coronary heart disease?

How does coronary heart disease form?

What are the risk factors for coronary heart disease?

What investigations would a patient have that was admitted with chest pain?

What is the role of the nurse when a patient is admitted with chest pain?

What are the roles of the rehabilitation nurse and the clinical nurse specialist?

Identify a patient with coronary heart disease, what health promotion could you
do for them and why?
Angina

What is angina?

What is unstable angina?

What are the signs and symptoms of unstable angina?

What happens to the ECG in unstable angina?

What investigations will diagnose angina?

What are the drug treatments for angina and what advice would you give to a
patient regarding these drugs?
Myocardial Infarction

What is a myocardial infarction (MI)?

What are the signs and symptoms of a MI?

What happens to the ECG in an acute MI?

What is the significance of a raised enzyme (CPK, Troponin I, Troponin T)?

What are the nursing priorities for a patient admitted with a MI?

What is the main drug treatment for a patient admitted with a MI?

What are the contraindications and potential side effects of this treatment?

What is the nursing care of the patient during thrombolysis?

What analgesics are used for the patient post MI and why are they used?

Why is it important to ensure that the patient is pain free?

What other groups of drugs are given to the patient post MI?
Pericarditis

What is pericarditis?

What symptoms does the patient have with pericarditis?

What usually happens to the ECG in pericarditis?

What is the medical management for pericarditis?

What is the nursing care of a patient with pericarditis?
Heart Failure

What is heart failure?

What are the symptoms of heart failure?

What is the medical management for a patient with heart failure?

What is the nursing care of a patient with heart failure?
Endocarditis

What is infective endocarditis?

What are the symptoms of endocarditis?

What is the medical management for a patient with infective endocarditis?

What is the nursing care of a patient with infective endocarditis?
Aortic Stenosis

What is aortic stenosis?

What are the symptoms of aortic stenosis?

What is the medical management of a patient with aortic stenosis?

What is the nursing care of a patient with aortic stenosis?
Rhythms

What is sinus rhythm?

What is sinus tachycardia?

What is sinus bradycardia?

What is the treatment for profound bradycardia?

What is atrial fibrillation?

What is the treatment for atrial fibrillation?

What is ventricular tachycardia?

What is the treatment for ventricular tachycardia?

What is ventricular fibrillation?

What is the treatment for ventricular fibrillation?

What is asystole?

What is the treatment for asystole?

What is pulseless electrical activity or electromechanical dissociation?

What is the treatment for pulseless electrical activity or electromechanical
dissociation?
Many Patients admitted to the chest pain unit have chest pain that is caused by
something other problems than Acute Coronary Syndrome, these include:











Pericarditis
Myocarditis
Pulmonary Embolism
Chest Infection
Hypertensive Heart Disease
Valvular Disease
Musculoskeletal Pain
Anxiety
Gastritis
Oesophagitis
Arthritis
Glossary of terms & abbreviations you might come across
ABG - arterial blood gas
ACS - acute coronary syndrome
AF - atrial fibrillation
AMI - acute myocardial infarction
Angio - angiogram/ angiography
APTT - actual pro-thrombin time
ASD - atrial septal defect
CABG - coronary artery bypass graft
CCF - congestive cardiac failure
CHD – Coronary heart disease
CPAP - continuous positive airways pressure
CVP - central venous pressure
ECG - electrocardiogram
Echo - echocardiogram
EPS - electrophysiological studies
ETT - exercise tolerance test
EMD - electromechanical dissociation
ICD - implantable cardiac defibrillator
IHD - ischaemic heart disease
INR - international normalised ratio
LVF - left ventricular failure
(N)IDDM – (Non) insulin dependent diabetes mellitus
NSF - national service framework
(N)STEMI – (Non) ST elevation myocardial infarction
PE – Pulmonary embolism
PEA - pulseless electrical activity
PPM - permanent pacemaker
PTCA - percutaneous transluminal coronary angiogram
r-tPA - tissue plasminogen activator
SR – Sinus Rhythm
Strep – streptokinase
SVT – Supraventricular tachycardia
TOE - trans-oesophageal echocardiogram
TIMI – thrombolysis in myocardial infarction
TNK - tinecteplase
TNT – troponin T
TPW - temporary pacing wire
UAP – Unstable angina pectoris
VE - ventricular ectopic
VF - ventricular fibrillation
VSD - ventricular septal defect
VT - ventricular tachycardia
Evaluation of Chest Pain Unit Student Pack
This learning pack has been put together to support the student in practice and help to
facilitate you in achieving your learning outcomes. As such it would be extremely helpful
if you would spend some time in completing the following questionnaire.
1). Did you receive the pack on your first day?
YES/NO
Please comment……
2). Did the pack aid you in writing your learning contract?
YES/NO?
Please comment……
3). During your allocation, how often did you work with –
Your Mentor
Your Associate Mentors
Additional Comments:
4). Did you visit any other areas during your allocation?
Please list and explain how they helped/hindered learning.
5). Are there any other comments you would like to make about the pack?
On completion please return this evaluation to your Mentor.
Thank you