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Contents
Contents List
Ward profile
Team Structure
Induction List
Ward Philosophy of Care
Coronary Heart Disease
Investigations
Medications
Chest Pain
12 Lead ECG
P.O.L.O
Learning Zones
Ward Profile
Ward 5 is a twenty -five bedded medical ward, which specialises in
cardiology, but also accommodates general medical patients. The
ward operates on a team nursing system of care, however whenever
possible we try to incorporate primary nursing principles. The ward
is divided into two teams the A team and the B team. The ward has
four, four bedded bays, generally theses are two male and two
female, a seven bedded bay, which is always male and two side
rooms, they are then divided between the two teams so that one
team has twelve beds and a side room and the other eleven beds
and a side room.
The nursing staff work in shifts, these consist of early shifts (7.5 hrs), late shifts
(7.5 hrs), a twelve-hour (11.30 hrs) or night shifts (10.71).
Early shift 07.45 – 14.45
Late shift 13.15 – 20.15
Twelve hour 07.45 – 20.15
Night shift 20.00 – 08.00
Ward 5 encourages learning at all levels and welcomes learner nurses at all
stages of their training on to the ward and we aim to give an informative and
enjoyable experience. During your placement on Ward 5, you will be working
along side staff that are highly skilled and motivated who will provide you with
knowledge, skills and support to facilitate the best possible care for our patients.
While placed on the ward we encourage you to ask questions and to ask for
help when needing assistance or in a situation of uncertainty.
Ward Team
1 Ward Manager/Ward Sister
1 Junior Sister Educational lead (full time)
1 Junior Sister Staff development (part time)
13 Staff nurses (Band 5)
7 Health Care Assistants
1 Ward Clerk
1 Physiotherapist (and aide)
1 Pharmacist
1 Housekeeper
Cardiology Medical Team
4 Consultant Cardiologists
2 Registrar’s
3 Senior house officers
1 House officer
Cardiology Team
Modern Matron
Coronary Care Unit
Cardiac Catheterisation Lab
Nuclear Physics Department
Cardiology Nurse Practitioners
Heart Failure Nurse Practitioners
Cardiac Rehabilitation Team
Electrocardiograph Department
Induction Checklist
Orientation Date
Shown around working environment
Introduced to staff members
Off duty organized
Procedure for reporting in sick
Discuss dress code
Explanation of POLO and Learning Zones
Location of Educational resource box identified
Location of hospital policies and Marsden manual
Emergency phone numbers
Emergency exists
Fire drill
Fire extinguishers
Mentor Name…………………………. Signed……….…………………..
Learner Name………………………… Signed…………………………..
WARD 5 PHILOSOPHY
We believe that our main focus is the patients’ right to receive nursing and medical care in a safe and therapeutic environment provided by caring, educated and proficient practitioners. Our belief is that each patient is an individual and as such we will endeavour to ensure that they are safeguarded from discrimination, that their ethnic origin, sexuality and religious beliefs are respected. It is important that people retain their dignity and self respect, being able to control their own lives and health needs. Our role cares greatly for the well-being of the patient and has recognised that the delivery of care must be holistic in nature; therefore involving the family (in its broadest term) encouraging those to take part in the delivery of care. Thereby allowing the patients and their relatives to express their concerns, fears, hopes and desires and allowing us as a team through development of relations promote caring partnerships where patients feel comfortable enough to express their inner feelings. The nursing team will provide support, education and advice so that the patient and their carers are able to make informed choices. As nurses we will strive to promote excellent standards of care and communication with patients and their carers. The care will reflect current research outcomes and also audits carried out by the Gateshead Health NHS Foundation Trust. To ensure ward 5 give the care as reflected in the philosophy we will ensure that as practitioners our skills and knowledge are kept updated and that we reflect upon our practice to maintain and explore new ways in delivering quality and timely care. We will pass these onto students who have learning requirements so that continuity of care is maintained.
February 2010
Coronary Heart Disease
While on ward 5 you will come across some terms or abbreviations that are
linked to the diagnosis and treatment of patients with coronary heart disease.
This section will try and cover such information.
Myocardial infarction (MI) Otherwise known as a heart attack. This occurs when
a blood clot blocks an artery in the heart stopping the flow of blood containing
oxygen to an area of the heart. If this is prolonged this area of muscle will die
resulting in an MI.
Non ST Elevation MI (NSTEMI) This is an MI, that when an electrocardiograph
(ECG) is taken, shows no elevated changes on the ECG within the ST segment.
However, the MI is diagnosed from the raise in Troponin T (Trop T) a specific
blood test that looks for proteins released from the heart when damage occurs.
ST elevation MI (STEMI) This is an MI which when the ECG is taken shows a
raise in the ST segment of the ECG which indicates an MI.
Angina This is used to describe pain, or discomfort in the chest and can radiate
to the neck, jaw and left shoulder and arm. It is brought on by exercise and is
caused through a lack of blood getting to the heart due to narrowing of the
arteries.
Unstable Angina This is the same as above, but the pain will develop at rest,
which can indicate the arteries are even narrower.
Coronary Heart Disease This is the narrowing of the arteries in the heart,
resulting in conditions such as hypertension (raised blood pressure) and angina.
Acute Coronary Syndrome (ACS) This is a term that is used to describe a
collection of conditions caused through a dislodged hardened clot.
1. unstable angina
2. NSTEMI
3. STEMI.
Heart Failure This is a collection of fluid around the lungs, through reduced
pumping of the heart, which will cause the patient to feel breathless and
develop swollen feet and legs (oedema).
Arrhythmias These are abnormal heart rhythms, which can be life threatening.
Common conditions are bradycardia (slow), tachycardia (fast) and Atrial
Fibrillation (AF).Arrhythmias can be caused by disease, by damage to the heart
or an imbalance in electrolytes.
Cardiogenic shock This is caused by inadequate blood supply to vital organs
due to heart failure, resulting in metabolic disturbances.
Investigations
Electrocardiograph (ECG) This is a printed interpretation of the electrical
activity in the heart, it shows the hearts rate and rhythm and can pick up
changes caused by an MI (e.g. ST segment).
Echocardiogram (Echo) This is a test that can identify if there has been any
damage to the heart following an MI, it mainly looks at the function of the
ventricles (the bottom chambers of the heart) and the valves in the heart. The
way in which it is performed is similar to that of a scan of an unborn baby.
Myocardial Perfusion Scan (MIBI) This looks at how well the heart receives
blood and can indicate areas that are damaged as a result of an MI. It is done in
two parts, a stress test and a rest test which are done on two different days.
When patients are having the stress test they are not allowed caffeine for 12
hours before.
Angiogram (Angio) This is performed in the cardiac cath lab and patients need
to be nil by mouth for 4 hours before the procedure. This procedure looks at the
condition of the arteries and identifies the location of any blockages or
narrowings. It is done by passing a tube (the catheter) through the groin which
goes up into the heart, dye is then injected up which highlights the pathway of
the blood when filmed by x-ray and identifies any problems.
Angioplasty (PCI) This is performed in the same way as the angiogram, but
where the blockages are a balloon is passed down the catheter and inflated
which opens the artery up, sometimes it is necessary to put a stent in, which is
a device that stops the artery from closing again.
Coronary Artery Bypass Grafts (CABG) This is an operation to bypass
narrowed sections of coronary arteries to improve blood supply to the heart.
Veins are taken from the legs and grafted onto the blocked artery to make the
new path for the blood flow.
Commonly Drug Groups
Nitrates
Nitrolingual Spray (GTN), Suscard buccal, Isosorbide Mononitrate (ISMN) and
Isoket (isosorbide dinitrate). These medications are used to relieve angina pain
or prevent angina attacks, they can also be used to reduce left ventricular
workload in heart failure. Nitrates have a vasodilatory effect which relaxes the
muscle wall of the arteries and veins allowing more oxygenated blood to flow to
the heart. Because of the nature of this medication it can cause headaches,
flushing, dizziness and hypotension.
Beta-Blockers
Atenolol, Bisoprolol and Metoprolol. These medications are used to control the
symptoms of angina, control hypertension and to prevent the incidence of
reinfarction and can also be used within the management of arrhythmias. The
medication blocks hormones that raise the heart rate, therefore lowering the
heart rate and the amount of oxygen needed by the heart. Beta blockers should
be used with caution with patients who have chronic obstructive pulmonary
disease and avoided with patients who have heart block and severe
hypotension. Beta blockers can cause patients to feel fatigued, have sleep
disturbances and cold extremities.
Ace Inhibitors
Lisinopril, Ramipril and Perindopril. These medications are used to treat heart
failure and hypertension, they aim at improving symptoms, improving exercise
tolerance and mortality. This medication works by inhibiting the angiotensin
enzyme, which has a narrowing effect on the arteries, therefore when taken the
production of the enzyme is reduced allowing the arteries to relax and widen.
This medication can cause severe hypotension and can effect the function of
the kidneys, patients can experience tachycardia, cough, sore throat, nausea
and vomiting.
Anti – Platelets
Aspirin and Clopidogrel. These medications are given to prevent the formation
of thrombus (clots) within the arteries. The medication works by reducing
platelet aggregation inhibiting the formation of thrombus. Care should be given
to patients who are at risk of haemorrhage and should be avoided in those who
have a haemorrhagic disorder or are actively bleeding.
Statins
Simvastatin, Pravastatin and Atorvastatin. Theses medications are used to help
aid the lowering of blood cholesterol levels by inhibiting the enzyme involved,
resulting in a slower progression of coronary artery atherosclerosis. They
should be used in caution with patients who have liver disease or a high alcohol
intake. Patients can experience nausea and vomiting, headaches and
diarrhoea.
Diuretics
There are 3 different main types of diuretics thiazides:- bendrofluamethazide
and metolazone, loop:- frusemide and bumetanide and potassium sparing:-
amiloride and spironalactone. These medications are used to relieve different
types of oedema by promoting the excretion of water and salt from the body,
lowering arterial pressure and correcting pulmonary and systemic congestion.
This type of medication can cause imbalances in electrolytes in particular
causing low levels of potassium (hypokalaemia), they should be used with
caution in patients with severe renal impairment.
Chest Pain Assessment Who can get chest pain? What causes chest pain? What symptoms might the patient have?
What would you do?
12 Lead ECG
An ECG is the recording of the electrical activity within the heart.
The heart is a muscle and like all muscles it contracts, when it contracts it sends
off impulses which are then picked up through the electrodes (the stickers)
which are placed on the body.
However, as the ECG picks up all muscular activity such as that in the arms and
legs, it is very important that the patient is as still as possible while the machine
is picking up the data. If the patient starts talking this will also be picked up by
the ECG so it is therefore necessary to explain to the patient that he/she should
be as still and relaxed as possible and not to talk.
It is also very important for the electrodes to have good skin contact, if a patient
has dry, wet or greasy skin then the electrodes have difficulty in sticking, so the
area needs to be prepared prior to attaching the electrodes. If the patient has
excessive hair on their chest, the area where the electrodes are to be placed
will need to be shaved. Permission is needed from the patient before shaving
them.
Position of the electrodes
One electrode needs to be placed on each of the wrists and on the ankles,
however the electrode can be placed anywhere on the respective limbs for the
ECG to work. If the patient happens to have either a missing limb or limbs the
electrodes can be placed on the shoulders or the hips.
There are six electrodes that are to be placed on the chest, these however are more specifically applied as they need to surround the heart.
CARDIOLOGY
• Coronary Care • Thrombolysis Nurse • Rehabilitation Nurse • Cardiology Nurse Practitioner • MIBI • Cath Lab • ECG Department • RACPAC • T.O.E. • Resuscitation Officer • Medical Team • Cardiology at FRH
SPECIALITIES
• Respiratory Nurse • Lung Cancer Nurse • Macmillan Nurse • Tissue Viability Nurse • Vascular Nurse • Infection Control Nurse • MAU • Physiotherapist • Pharmacy
INVESTIGATIONS • Medical Physics • Radiology • Gastroscopy • Colonoscopy
NUTRITION • Dietician • Diabetic Nurses • S.A.L.T. • Nutritional Specialist Nurses
SOCIAL
• Discharge Liaison Nurse • Elderly Care Practitioner • CROP/ICIS • Bed Managers
Ward 5
LEARNING
ZONES
LEARNING OPPORTUNITIES RESOURCE/PERSONNEL
CLINICAL OPPORTUNITIES CARDIOLOGY
Myocardial Infarction
Staff/
CCF/LVF
nurses
Angina
Arrhythmias/Telemetry
dpt/Radiology
Cardiac Rehabilitation
Cardiac Investigations: MIBI, Angiography,
Echo, TOE, ECG.
Haemostasis /Disturbances
Cardiac Drugs/Thrombolysis
Smoking cessation
RESPIRATORY
COPD/Asthma
Nurses/Respiratory Nurses
Drugs/Oxygen/Nebuliser Therapy
technicians/
Infections
Chest X-rays
specialist
Investigations: CT scan/VQ
scan/bronchoscopy
Pulmonary Function Tests
Treatments
Lung Cancer
Trained Nurses/Medical
CCU/Cardiology Specialist
Resource Room/Library/ Pharmacy/ECG
Clinical pathology services
Trained
Medical Staff/ECG
Pharmacy/Radiology
Lung cancer nurse
GASTRO-INTESTINAL SYSTEM
Investigations: Endoscopy/Colonoscopy
Nurses/Dieticians
Nutrition: Food Charts/Weight
nurses
Monitoring
Dietician
Naso-gastric/PEG tubes and feeding
Trained /Untrained
Nutritional specialist
ENDOCRINE SYSTEM Diabetes staff
Thyroid function
Trained nurse/Medical
Diabetic nurse specialist
NERVOUS SYSTEM CVA
Epilepsy nurse
Parkinson’s Disease research
Medical staff/Parkinson’s
Dysphagia nurse/Stroke Team
HAEMATOLOGY Blood disorders Staff Haemorrhage Nurse
Trained Nurses/Medical Blood Transfusion Nurse/Haematology
NURSING CARE Hygiene Nurses Mouthcare Continence /Elderly Pressure area care Falls Catheter Care Privacy and Dignity Principles of Self Care Communication
Trained/Untrained Tissue Viability Nurse Continence Advisor
Care Team
CARE MANAGEMENT
RISK MANAGEMENT
Risk Assessments/Tools Leads Clinical Incident Recording Health and Safety Policies and Procedures Medical Devices Infection Control Moving and Handling Falls
Trained Nurses/ Ward
Resource Room
RESOURCES Resource Room Manager Cardiology Workbooks Library Staff Rota Drugs/Stock/Equipment Ordering Budgets Internet/E-mail
Trained Nurses/Ward
Pharmacist
NURSING PROCESS Assess Plan Implement Evaluate
Trained/Untrained Nurses
STAFF SERVICES/DEVELOPMENT Clinical Supervision Philosophy of Care Essence of Care NSF’s CONTACT’s Training Files/Training Opportunities Preceptorship Portfolio Rotational Posts Staff Library NVQ Resource Room Cardiology Workbooks
Trained Nurses/Ward Managers
EMERGENCY SITUATIONS Cardiac/respiratory arrests Clinical incident Fire
Trained nurses/Ward manager
Fire officer/Resuscitation officer
TEAM MANAGEMENT Organisation Delegation Prioritising Leadership Managing change Standards of care Quality Time/Workload management
Trained nurses/Ward manager
12 Lead ECG
A 12 lead ECG is a recording of the
electrical activity occurring in the heart
each time the heart contracts.
12 different views of the same activity are
demonstrated on the ECG graph paper.
Each separate view of the heart is called a
“lead”.
Electrodes are placed on both wrists and
the left ankle forming a triangle, known as
Einhovens triangle.
The fourth electrode, which is on the right
ankle is to stabilize the ECG but takes no
part in the formation of the ECG.
These leads are the limb leads and form 6
of the 12 leads on the ECG. The other 6
leads are placed over the chest. (See
Diagram Below)
V1 (red) – Is positioned at the fourth
intercostals space at the right of the
sternal margin.
V2 (yellow) - Is positioned at the fourth
intercostals space at the left of the
sternal margin.
V3 (green) – Is at the fifth intercostals
space between V2 & V4.
V4 (brown) – Is at the fifth intercostals
space mid clavicular line
V5 (black) - Is mid way between V4 & V6.
V6 (purple) - Is at the fifth intercostals
space mid auxillary line
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