Download welcome to cardiac medicine at at the royal victoria infirmary

WELCOME TO CARDIAC MEDICINE
AT
AT THE ROYAL VICTORIA INFIRMARY
OCCUPATIONAL THERAPY DEPARTMENT
Last updated Aril 2010
CONTENTS
1
Introduction to the Royal Victoria Infirmary Hospital
2-4
Wards and Specialism
5-7
Ward Profiles
8
Palliative Services
9-12
Frequent presenting conditions
13
Classes of Cardiac Disease
14
Cardiac Rehabilitation & Heart Failure Programme
15
Falls & Syncope (FASS)
17
Assessment/screening tools
18
Supervision
19
Prioritisation criteria
24
Theoretical Models guiding practice and recommended reading
Last updated Aril 2010
ROYAL VICTORIA INFIRMARY HOSPITAL, NEWCASTLE UPON TYNE
Welcome to the Royal Victoria Infirmary hospital (RVI) occupational therapy service
in Medicine. The RVI is a regional, specialist hospital providing care and specialist
services to local people and to clients from other geographical regions of the
United Kingdom. The occupational therapy role within this healthcare context is to
provide timely and safe discharge to clients. There are eight wards within this
specialty, staffed by 1.8 whole time equivalent senior occupational therapists 2
basic grades and two part time assistants..
The purpose of this handbook is to offer you the student an over view of the
possible learning experiences and resources available to you on this placement.
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Ward 22 – Diabetes, Endocrinology Ward (Acute Medicine), consisting of 6 x four
bedded bays and five individual cubicles.
Conditions seen include: Diabetic keto-acidosis, Hypoglycaemia, Hypothyroidism,
Urinary Tract Infection.
Ward 49 Cardiology Ward, consisting of 4x six bedded bays and five individual
cubicles.
Procedures/conditions seen include:
multiple conditions such as Myocardial
infarction, Angina, Arrhythmias.
This ward also generates a high proportion of the OT caseload and is visited most
days to collate information and current condition of clients.
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WARD PROFILES
Ward:
22
Ext:
Nurses Station
Doctors Room
Sisters Office
Consultant:
Diabetes
1.
Prof R Taylor, Professor of Medicine and
Metabolism & Diabetes
2.
Dr S Marshall, Consultant Physician/Reader in
Diabetes
3.
Dr N J Leech, Consultant Physician, Diabetes
Endocrinology:
1.
Dr R A James, Consultant Endocrinologist
2.
Dr Quinton, Consultant Endocrinologist
3.
Dr S G Ball, Consultant Physician Endocrinologist
General Medicine
4.
Dr Jay General Medicine
5.
Dr Wynne General Medicine
Ward Manager
Ellen Horsburgh (Ward Sister)
Ward Clerk:
Patricia Hands (Pat)
Team Divisions (Nursing):
Divided into two teams
Team A, beds 1 – 12 and cubicles 1 – 3
Team B, beds 13 – 24 and cubicles 4 – 5
Ward Round:
Variable
MDT Meeting:
2. pm Tuesday Social Round (OT, SW and nursing staff,
Ward 22, Day Room).
Method of referral to
Occupational Therapy:
Via social meeting, Tuesday and Thursday handover
Informally on Ward, By telephone
Social Worker:
Helen Warwick – 24594
Physiotherapist:
Rotational (Junior Physiotherapist)
Part-Time Physiotherapy Assistant
Method of communication
With Ward:
Via handover, nursing kardex and telephone
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(Diabetes and Endocrinology)
Door Coded
20122/20121
24360
20119
Rehab room (located
Door coded
Outside Wards 22 and 23): Ext. 20127
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Ward:
49
(Cardiology)
Ext:
Nurses Station
Doctors Room
Sisters Office
Consultant:
Ward Manager
1. Dr Skinner, Consultant Physician,
Cardiology
2. Dr Adams, Consultant Physician,
Cardiology
3. Dr Mc Neil, Consultant Physician,
Cardiology
4. Dr Irvine, Consultant Physician,
Cardiology
5. Dr Haq, Consultant Physician,
Cardiology
Marian Phebey (Ward Sister)
Ward Clerk:
Anne Herron
Team Divisions (Nursing):
Divided into two teams
Team 1, beds 1 – 12 and cubicles 28, 29
Team 2, beds 13 – 27 and cubicles 25, 26, 27
Ward Round:
Variable
MDT Meeting:
Wednesday 2pm
Method of referral to
Occupational Therapy:
Via Wednesday mdt meeting, Informally on
Ward
By telephone
Social Worker:
Helen Warwick – 24594
Physiotherapist:
Laura Cliffe band 7 Physio
Rotational junior and assistant
25649
25090
24202
Method of communication
With Ward:
Via handover, nursing kardex and telephone
Rehab room (located
Near wards 48 & 52):
Door coded
Last updated Aril 2010
Due to the nature of some of the conditions within acute medicine the occupational
therapist is sometimes required to deal with issues of a sensitive nature e.g.
patients with a palliative condition.
PALLIATIVE OCCUPATIONAL THERAPY
The OT role is central to the assessment, preparation, planning and co-ordination
of clients who wish to return to their home.
Palliative care involves working with clients who have to live with a degree of
uncertainty as to the course their illness may take and the length of life they may
expect. This client group can account for approximately 25% of the caseload at any
one time.
Before approaching the client the MDT documentation is reviewed and discussion
takes place within the team as to the clients understanding of their condition, their
physical, psychological, and emotional state. This information guides the OT’s
professional approach.
This area can be emotionally demanding and the OT requires support
mechanism’s for herself i.e. supervision, MDT support and reflection. This area can
also be very rewarding in which the OT is not only central to satisfactory and safe
discharge, but also in that we may enable the clients wishes and views to be
fulfilled. This means all clients irrespective of age, illness, disability or any other
circumstances are considered as people first. Throughout the intervention the aim
is to enable the client to take back some control in their life whilst not distracting
them from important issues they may have to deal with.
Our greatest contribution is to observe, listen and work holistically with each client
to achieve their particular aim, to ensure they have quality of life. Most importantly
we allow the person time to talk, space to think and to remain in control.
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Information on frequently presenting conditions with patients from Ward 22:
Diabetes – any disorder of metabolism causing excessive thirst and the production
of large volumes of urine. Used alone, the term most commonly refers to diabetes
mellitus.
Diabetes mellitus – a disorder of carbohydrate metabolism in which sugars in the
body are not oxidized to produce energy due to lack of the pancreatic hormone
insulin.
The accumulation of sugar leads to its appearance in the blood
(hyperglycaemia), then in the urine; symptoms include thirst, loss of weight, and
the excessive production of urine. The use of fats as an alternative source of
energy leads to disturbances of the acid base balance, the accumulation of
ketones in the bloodstream (ketosis), and eventually to diabetic coma.
Diabetic ketoacidosis – a condition in which acidosis is accompanied by ketosis,
such as occurs in diabetes mellitus.
Symptoms include nausea and vomiting,
abdominal tenderness, confusion or coma, extreme thirst, and weight loss. It is a
life-threatening situation.
Hypoglycaemia – a deficiency of glucose in the bloodstream, causing muscular
weakness and in-coordination, mental confusion, and sweating.
Hypothyroidism – subnormal activity of the thyroid gland. If present at birth and
untreated it leads to cretinism. In adult life it causes mental and physical slowing,
undue sensitivity to cold, slowing of the pulse, weight gain, and coarsening of the
skin.
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Urinary tract infection – urinary tract is the entire system of the ducts and channels
that conduct urine from the kidneys to the exterior. It includes the ureters, the
bladder, and the urethra.
Exacerbation of COPD – generalised airway obstruction, particularly of the small
airways, associated with varying combinations of chronic bronchitis, asthma, and
emphysema. The term was introduced because these conditions may co-exist and
it may be difficult to decide on which one is producing the
obstruction. COPD is generally progressive, may be accompanied by airway
hyperactivity, and may be partially reversible.
Chest infection/bronchitis – characterised by a chronic productive cough for at least
three months in each of two successive years for which other causes have been
excluded ie infection, cancer, and chronic heart failure.
Dementia – a chronic or persistent disorder of behaviour and higher intellectual
function due to organic brain disease. It is marked by memory disorders, changes
in personality, deterioration in personal care, impaired reasoning ability, and
disorientation.
Information on frequently presenting conditions with patients from Ward 49:
CARDIOPULMONARY DISORDERS
Cardiopulmonary disorders encompass cardiovascular disease and chronic
obstructive pulmonary disease.
CARDIOVASCULAR DISEASE – affects the blood supply, tissues, and muscles in
and around the heart and vascular system of the body. Diseases include:
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Arterial hypertension – is elevated systolic blood pressure (BP) at or above 140mm
of mercury and/or diastolic pressure blood pressure at or above 90mm of mercury.
Treatment with drugs known to lower blood pressure.
Orthostatic hypotension
- is an excessive fall in BP it is not a disease but a
manifestation of abnormal regulation.
Syncope – sudden, brief loss of consciousness, with loss of postural tone (faint).
Arteriosclerosis – generic term for several diseases in which the arterial wall
becomes thickened and loses elasticity. Atherosclerosis is the most common form
that can result in reduced blood flow.
Coronary artery disease – includes Angina and Myocardial Infarction (MI). Angina
is due to ischemia precipitated by exertion and relieved by rest or nitro-glycerine.
MI is necrosis within the myocardium due to abrupt reduction of the coronary flow
within the heart muscle.
Heart failure – is myocardial dysfunction resulting from a haemodynamic, renal and
neurohormonal response in which the plasma volume increases and liquid
accumulates in the lungs, and abdominal organs such as the liver, and peripheral
tissues.
Shock – is a state in which blood to and perfusion of peripheral tissues are
inadequate to sustain life because of insufficient cardiac output or maldistribution of
peripheral blood.
Arrhythmias – include bradycardia (slow) or tachycardia (fast). Usually not clinically
significant unless they are sustained and cause dizziness or syncope.
Cardiac arrest – the absent or inadequate ventricular contraction resulting in
circulatory failure.
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Valvular heart disease – occurs when the mitral, tricuspid, and aortic heart valve
fails to function correctly.
Endocarditis – inflammation of the endo-cardium of the heart.
Pericardial disease – congenital disorders and acquired disorders.
Disease of the Aorta and it’s branches – includes aneurysms, aortic dissection,
inflammation and occlusion.
Peripheral vascular disorders – affects the arteries, veins and lymphatics of the
extremities.
CAUSES
The causes of cardiovascular disease include blood clots, thickening of the arterial
walls, bacterial infections that result in damage to the valves, high BP, arrhythmias,
and other contributing or lifestyle factors, such as diet and nutrition, lack of
exercise, high stress jobs, and poor health. This also includes:
Risk factors like age, sex, family history, smoking, and obesity.
Metabolic diseases such as diabetes.
Congenital conditions, cysts or absence of the parietal pericardium.
CLASSES OF CARDIAC DISEASE
Class 1 – these clients have cardiac disease but not the resulting limitation of
physical activity. Ordinary physical exertion does not cause undue fatigue,
palpitations, dyspnoea, or anginal pain.
Class 2 – cardiac disease is present and there is some resultant limitation of
physical activity. Comfortable at rest. Therefore ordinary physical exertion results in
fatigue, palpitations, dyspnoea, or anginal pain.
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Class 3 – cardiac disease present and results in marked limited physical activity.
Comfortable at rest. Less than ordinary physical activity causes fatigue,
palpitations, dyspnoea, or anginal pain.
Class 4 – cardiac disease resulting in an inability to carry on any physical activity
without discomfort. Symptoms of cardiac insufficiency or anginal symptoms may be
present even at rest. Any physical activity will increase discomfort.
CARDIAC REHABILITATION
Once clients are discharged from the acute setting local clients may return for out
patient services in cardiac rehabilitation (CR). The goal of CR is to return the client
to the highest possible level of functional capacity through education, excise
training and psychosocial support. This is carried out in the group setting at
Freeman Hospital in the evening.
HEART FAILURE PROGRAMME
The service provides a weekly rehabilitation session (Wednesday morning)
supporting home based physical activity, and providing information and support to
people with heart failure and their relatives.
Besides improving/sustaining
functional activity and quality of life, the service will hopefully contribute towards
meeting the NSF target of reducing readmissions from heart failure.
Role of occupational therapy
The senior occupational therapist, responsible for the occupational therapy
interventions for patients attending this group, provides assessment and
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intervention for the patients. The occupational therapist works closely with other
members of the team, ensuring an interdisciplinary approach to patient care.
Aims of occupational therapy within the heart failure group
On a weekly basis, participants have the opportunity to discuss their perceived
condition and activities/goals. The aim of occupational therapy within the group is
mainly educational:
Teaching participants how to pace activities of daily living
Offer information on support networks for carers
Information on various benefits available
Opportunity to learn and practice relaxation techniques
The occupational therapist is available during each session to offer support to
patients, discuss any changes/anxieties/problems with regard to activities of daily
living, and depending on the needs of each individual, provide any necessary
equipment to maintain independence with daily living.
FALLS AND SYNCOPE SERVICE (FASS)
In April 2005 the Newcastle Integrated Falls Service was launched, which
comprises 4 main services:
Falls and Syncope Unit at the RVI(FASS)
Melville (Freeman Hospital) and Belsay (Newcastle General Hospital) Day
Hospitals
Osteoporosis Services (Bone Clinic at Freeman Hospital and Fracture Clinic
at Newcastle General Hospital)
Community Resource Teams for Older People (North, West and East
Teams within the Primary care Trust (PCT)
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This development was in response to the National Service Framework (NSF) for
Older People.
The OT service (9 hours) is provided via FASS at the RVI for people who are at
risk of falling or have a history of falls. The aim is to reduce the environmental risk
to people of falling at home.
Occupational Therapy analyses the activities an
individual engages in as part of their daily living to identify potential risks.
Subsequent information and advice given to people, who have had a fall, increases
their awareness of the risks of further falls and how to prevent them. The aids and
adaptations provided enable the individual to become more independent in
Activities of Daily Living.
Information is gathered to highlight activities the individual was performing at the
time of the fall. Advice and information is given to the patient to enhance the
individual’s self-efficacy in fall-risk situations.
Information on frequently presenting conditions with FASS patients:
Syncope – Defined as transient loss of consciousness with loss of postural tone but
with spontaneous recovery.
Carotid sinus syndrome - a pocket in the wall of the carotid artery, at its division in
the neck, containing receptors that monitor blood pressure.
Assessment tools used within acute medicine:
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Functional Assessment Form (FAF) – within this functional assessment form the
modified barthel score is incorporated. This is a standardised tool, which is scored
at the end of the Occupational Therapy intervention and scores functional activities.
The Mini Mental State Examination (MMSE) – The patient is tested on aspects of
cognition such as memory, orientation, attention, language and praxis.
The Middlesex Elderly Assessment of Mental State MEAMS – was developed to
detect intellectual impairment due to organic brain dysfunction in the elderly. It
aims to survey the main areas of cognitive performance using a range of 12 subtests sensitive to the functioning of different cortical areas.
Assessment/Screening tools used with FASS patients:
Home falls and Accidents Screening Tool (HOMEFAST) – The HOMEFAST was
developed in Australia as a screening instrument to assist in the identification of
older people living in the community who are at increased risk of falls, trips, or
accidents at home. This is applied in practice as a screening instrument to identify
a possible 25 home hazards or combinations of hazards, which may put people at
increased risk of experiencing a fall in order to enable an effective preventive
intervention.
The hospital anxiety and depression scale (HAD) – A self-assessment scale
designed to detect the mood disorders of depression and anxiety in non-psychiatric
populations attending at other hospital departments e.g. medical clinics, post natal
clinics. However, experience has shown that it may be used with equal reliability in
community or general practice settings. This is used in practice to detect how
experiencing a fall has had an effect on patient’s confidence.
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Tinetti Self Efficacy Score – Patients are asked to record on a scale of 1 to 10 (1
being extremely confident and 10 having no confidence at all) how confident they
feel about activities of daily living. This scale is scored out of 100.
Functional Assessment Form – see above.
SUPERVISION
Supervision is central to your learning and induction to the occupational therapy
service. Formal supervision will be held either daily or weekly depending on your
way of learning and your supervisor’s time. Informal supervision will be available as
appropriate throughout the placement. It is a necessary requirement for the student
to plan and prepare for supervision by having their personal agenda items.
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NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST – REHABILITATION DEPARTMENT
OCCUPATIONAL THERAPY – REFERAL CRITERIA FOR MEDICAL WARDS RVI 2009
HIGH RISK REFERALS – URGENT < TWO DAY
∆
RESPONSE
MEDIUM RISK – THREE DAY RESPONSE
∆
LOW RISK REFERAL – Dependent upon capacity
after high-medium risk. Can these needs be met in
the community ?
Referrals to occupational therapy must include a deficit within a functional area shaded below
Level of function – recent deterioration
- mobility – major difficulties, supervision
required to mobilise safely, at risk of falls
- cognitive function - prompts / supervision
constantly required to maintain safety
- transfer – unable to transfer safely without
assistance or equipment
- self care – assistance needed with all aspects
of personal self care
Social circumstances
-
lives in house with stairs
-
lives alone/carer working full time
-
Inadequate services in situ
Discharge plans
-
Patient condition palliative and no support
services to follow
Limited life expectancy with discharge
imminent
Level of function – gradual deterioration
- mobility, recent provision of frame
- partial assistance with self care
- domestic tasks - previously completing main
meal increased difficulty reported
- problems with grip in the dominant hand
- fatigue and stamina problems – increasing
problems resulting in increasing fatigue
Level of function – minor deterioration
- independent mobilising, problems identified with
long distance mobility – requiring potential
wheelchair assessment
- residual problem that is being addressed by local
services
- patient independently self caring on ward but
identifies difficulties with bath or car transfer
issues
Social circumstances
Social circumstances
-
supported at home by home care or family,
carer concerns
-
-
known to services previously
-
-
lives in supported accommodation
-
Discharge plans
-
Further rehab required prior to discharge
-
Palliative condition
-
Will remain on acute ward at least 7 days
Housing inappropriate for long term need, but
few issues at present
Supported at home by home care / family
Patient is known to local services in place of
residence with regular therapy input
Discharge plans
-
Awaiting transfer to long term care
-
Not medically stable for intervention
Medically stable for intervention
Patient must have deficits within the shaded area and one or more of the categories to be included within that criteria
Service is from Monday to Friday 8:30 –16:15. The Occupational Therapists can be contacted on Extension 21266Dawn Tweedy SROT
Last updated Aril 2010
∆This is an example of the framework used for prioritising referrals. It is aimed to identify those at high risk who require our most urgent attention, not necessarily those who would benefit most from
Occupational Therapy. It is designed for use at point of referral based on information provided by the referrer at the time. Response times may be subject to variation depending on caseload and
staffing levels. These response times do not relate to timescales for discharge; this will be dependent on needs and resources available to access. Reviewed Aug 02 to be reviewed April10
Last updated Aril 2010
Theoretical Models Guiding Practice
Bio-Mechanical Approach
Compensatory Approach
Rehabilitation Approach
Problem Solving Approach
Recommended reading:
Childs, L., Kneebone, I.I (2002) Falls, fear of falling and psychological management.
British Journal of Therapy and Rehabilitation, Vol 9, No 6, p 225-231.
Fuat, A et al (2005) The diagnosis & management of heart failure across primary-secondary care: a
qualitative study. British Journal of Cardiology, Vol 12, (3), p 233-8.
Hagedorn, R. (1996) Occupational Therapy Perspectives and Processes.
Management. Churchill Livingstone.
Chapter 11.
Case
Hammond, J.M et al (1998) Patients’ perceptions of exercise based cardiac rehabilitation. British
Journal of Therapy and Rehabilitation, 5, (8), p406-8, 421-3.
Husband, H.J., Tarbuck, A.F. (1994) Cognitive rating scales: A comparison of the Mini-Mental State
Examination and the Middlesex Assessment of Mental State. International Journal of Geriatric
Psychiatry, vol 9, p 797-802.
Mackenzie, L., Byles, J., Higginbotham, N (2000) Designing the Home Falls & Accidents Screening
Tool (HOMEFAST): Selecting the Items. BJOT, 63, (6), p 260-369.
McQueen, J.M (2003) Falls management and prevention: a day hospital perspective.
British Journal of Therapy and Rehabilitation, Vol 10, No 3, p 115-121.
Tinetti, M., Baker, D., McAvay, G., Claus, E., Garrett, P., Gottschalk, M., Koch, M., Trainor, M.,
Horwitz, R (1994). A multifactorial intervention to reduce the risk of falling among elderly people
living in the community. New England Journal of Medicine, 331, (13), p 821-27.
Tipson, R. (1997) The exercise component of cardiac rehabilitation. British Journal of Therapy and
Rehabilitation, 4, (6), p316-22.
Welch, A & Foster, S. A. (2003) A Clinical Audit of the Outcome of OT Assessment and Negotiated
Patient Goals in the Acute Setting. BJOT, 66, (8), p 363-368.
www.cardiomyopathy.org
www.bjcardio.co.uk
www.heartuk.org.uk
www.britishheartfoundation.co.uk
Last updated Aril 2010
www.library.nhs.uk
Last updated Aril 2010