Download Objectives for Student Nurses - School of Nursing and Midwifery

RESPIRATORY SPECIALIST NURSES
STUDENT RESOURCE BOOK
NINEWELLS HOSPITAL
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INDEX
SECTION
PAGE
ONE- Introduction to Respiratory
Specialist Nurse Team and
Orientation
2
TWO- Lung Cancer Team
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THREE- Respiratory Liaison Team
15
FOUR- Cystic Fibrosis Team
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1
Section One
Introduction to the Respiratory
Specialist Nurse Team
2
Orientation
Date completed and initialled by
CNS
Introduction to mentor for each
Respiratory Specialism
Orientation to department
Emergency Procedures- Fire, CPR etc.
Professional Issues
Confidentiality, Dress code, Identification
and working hours
Specialism Specific Learning
Contract/Objectives
3
Identified Learning Experiences
Evidence of Achievement
Evaluation
4
Reflection / Comments
Useful Contact
5
Section Two
Lung Cancer Team
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LUNG CANCER SERVICE
RESOURSE PACK FOR STUDENT NURSES
Name ……………………………………………………..
Commencement Date ……………………………………................
Lung Cancer Nurses:
Susan Smyth, Gillian Watson, Adele Murray
Lung Cancer Patient Co-Ordinator:
Laura Shepherd
Welcome
During your placement with the lung cancer specialist nurses (CNS) you will be given the
opportunity to expand your clinical knowledge and experience of the lung cancer and
mesothelioma patient’s pathways.
The lung cancer team provide a hospital based Tayside service. The service aims to
provide support and information to patients throughout their lung cancer journey,
whilst utilising all members of the multidisciplinary team to ensure that the patients
quality of life is maximised.
You will be offered the opportunity to observe the CNS working with this vulnerable
group of patients. You will also have opportunities for discussion and tutorials on a
variety of subjects, depending on your interests.
The CNS will provide you with a timetable, however this is only a guide and can be
adapted to suit your learning experience.
During your first few days, the CNS will identify a patient for you to follow on their
journey. The information enclosed in this pack should enable you to understand the
outcomes agreed for your patient.
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LUNG CANCER CLINICAL NURSE SPECIALIST (CNS) SERVICE
LEARNING RESOURCE PACK
AIMS OF RESOURCE PACK:
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Provide the student with an overview of the lung cancer CNS role
Give a brief overview of the structure and function or the lung
Explore factors involved in the causes of different tumour types
Increase awareness of the impact of lung cancer/mesothelioma on patients and
carers including physical, psychological and socio-economic factors
Present an overview of currently available treatment options including the impact
that treatments may have on the patient/carer
Explore palliative care issues in nursing lung cancer/mesothelioma patients
Act as a resource to be used in conjunction with experiential learning with a lung
cancer CNS and guide development of personal learning outcomes
LEARNING OBJECTIVES
 To understand the lung cancer patient pathway from pre-diagnosis onwards
 To identify key members of the lung cancer team and their roles
 To identify key investigations to diagnosis lung cancer
 To identify the symptoms of patients with lung cancer and the effect of local and
wide spread disease
 To understand the process involved in communicating diagnosis
 To discuss the relevance and timing of information to patients and their families
 To understand the role of the CNS
 To identify the importance of the extended multidisciplinary team, primary,
secondary and tertiary care; statutory and voluntary organisations in providing care
to lung cancer patients
 To identify and discuss the role of the most common treatments for lung cancer
 To discuss pharmacological approaches to symptom control
 To identify the role of the specialist palliative care team
 To identify the common psychosocial issues for patients with lung cancer
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Identified learning experience
Date completed –CNS initials
Bronchoscopy
Pulmonary Function
CT scan/CT guides biopsy
PET CT scan
Oncology clinic- Ninewells and PRI
Nurse Led Clinic
Lung Cancer MDT
Chest Clinic
Ward 32 meeting
Ward referrals
EBUS
EUS
Identified subject for discussion Date completed – CNS initials
Lung cancer
Mesothelioma
Communicating diagnosis
Diagnosing thoracic malignancies
Treatment of thoracic malignancies
Symptom control
Palliative care
Communication skills and issues
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Lung cancer pathway
LUNG Cancer Pathway
1 -14 days
14 – 31 days
Referral
Investigations
31 – 62 Days
DTT
Trigger Point Day 45
Escalate
Trigger Point Day 20
Escalate
CT
Staging
First Treatment
1st Chest Clinic
Appointment
Diagnosis
MDT
Day 1 -14
CT Scan prior to clinic. First appointment at Clinic with spirometry and CNS review (assess co-morbidities and performance status at this time)
Day 14 -31
Investigations for diagnosis and staging:- May Include more than one of the following: Bronchoscopy, CT guided lung biopsy or EBUS. This process may
include more than on discussion at MDT and review at Nurse Led Clinic.
MDT – Staging +/ - tissue diagnosis
IF RADICALLY TREATABLE: FOR PET SCAN and CT BRAIN > then either
Surgical referral > mediastinoscopy (Results of this would be date decision to treat if mediastinoscopy negative) Proceed to surgery
> If mediastinoscopy positive then back to Oncology in Dundee
IF FOR PALLIATIVE TREATMENT: either
> Oncology referral – discuss palliative treatment
OR
Best Supportive Care
Day 31 – 62
Date decision to treat:
Radical treatment – either surgery or radical radiotherapy/ radical chemo/ radiotherapy
Palliative treatment – either palliative chemotherapy/ radiotherapy or best supportive care
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BREAKING BAD NEWS MODEL
Buckman’s 6-step guide
S.P.I.K.E.S.
S etting, listening Skills
P atient’s Perception
I nvite patient to share Information
K nowledge transmission
E xplore Emotions and Empathize
S ummarize & Strategize
Adapted from: Buckman, R., M.D., Breaking Bad News: A Six-Step
Protocol. How to Break Bad News: A guide
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Lung Cancer TNM Staging Breakdown

Tx – The tumour size is unknown, or cancer cells are only found in sputum. There is no evidence of a
primary tumour.

Tis –Carcinoma in situ – The tumour is present only in the cells lining the airway and has not spread to
nearby tissues.
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T1 – Tumours less than or equal to 3 cm (1 ½ inches).

T1a – Less than or equal to 2 cm.
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T1b – Greater than 2 cm but less than or equal to 3 cm.
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T2 – The tumour is greater than 3 cm but less than 7 cm. T2 tumours may block part of the airway, but
have not resulted in pneumonia or caused the lung to collapse (atelectasis). They may have spread to
the lining around the lungs. They may also be close to the main bronchus, but are at least 2 cm (about an
inch) away from the area in which the bronchus divides to go to each of the lungs.

T2a – Greater than 3 cm but less than or equal to 5 cm.
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T2b – Greater than 5 cm but less than or equal to 7 cm.
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T3 – Tumours greater than 7 cm, or less than 7 cm but with a separate nodule in the same lobe. T3
tumours also include tumours that are less than 7 cm but invade the lining of the lung (pleura), the chest
wall, the diaphragm, the main bronchus, or lie within 2 cm of the area where the bronchus divides to
travel to the lungs. A tumour is also classified as T3 if it is less than 7 cm but is associated with
pneumonia or collapse of the entire lung.

T4 – A tumour of any size, but with another nodule in a different lobe on the same side of the body, or a
tumour that invades structures in the chest such as the heart, major blood vessels near the heart, the
trachea, the recurrent laryngeal nerve (a nerve near the trachea), the mediastinum (the space between
the lungs), the oesophagus, or the area where the main bronchus divides to travel to the two lungs.

N – Involvement of Lymph Nodes

N0 – No nodes are involved
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N1 – The tumour has spread to nearby nodes on the same side of the body.
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N2 – The tumour has spread to nodes farther away, but on the same side of the chest.

N3 – The tumour has spread to lymph nodes on the other side of the chest from the
original tumour, or has spread to nodes near the collarbone or neck muscles.
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M – Metastasis (Spread) to Other Regions

M0 - The tumour has not spread to distant regions.
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M1a – The tumour has spread to the opposite lung, to the lung lining (malignant pleural effusion) or
has formed nodules on the pleura.
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M1b – The tumour has spread to distant regions of the body, e.g. the brain or bone
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Cancer Staging
7th ed T+M N0 N1 N2 N3
Stage Stage Stage Stage
T1a(<_2cm) IA IIA IIIA IIIB
T1b
(>2-3cm)
IA IIA IIIA IIIB
T2a
(>3-5cm)
IB IIA IIIA IIIB
T2b
(>5-7cm)
IIa IIB IIIA IIIB
T3(>7cm)/ invasion IIB IIIA IIIA IIIB
T4
(extension/ipsilatera
l lung)
IIIA IIIA IIIB IIIB
M1a (pleural
effusion/
contralateral lung)
IV IV IV IV
M1b (Distant
metastasis)
IV IV IV IV
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USEFUL WEBSITES
http://www.show.scot.nhs.uk
http://www.macmillan.org.uk/Cancerinformation/Cancerinformation.aspx
http://www.nlcfn.org.uk/default.aspx
http://www.scan.scot.nhs.uk/default.aspx
RESPIRATORY ANATOMTY AND PYYSIOLOGY REVISION GUIDE. (only
available via staffnet – see link below)
http://staffnet.tayside.scot.nhs.uk/NHSTaysideDocs
www.bettertogetherscotland.com
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Section Three
Respiratory Liaison Team
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NHS TAYSIDE
Respiratory Nurse and Sleep Service
LEARNING RESOURCE PACK FOR STUDENT NURSES
Name ……………………………………………………..
Commencement Date ……………………………………
Nurses Ninewells and Perth:
Sandy Rolfe
Zoë Pickup,
Lynne Spence, Tracey Finch, Neil Lonie
Sleep Service:
Gail Spasic
AIMS OF RESOURCE PACK:

Provide the student with an overview of the Respiratory Nurse Service

Act as a resource to be used in conjunction with experiential learning with a
respiratory nurse service and guide development of personal learning outcomes
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Welcome
During your placement with the respiratory and sleep service you will be given the
opportunity to expand your clinical knowledge and experience of chronic obstructive
pulmonary disease, asthma and obstructive sleep apnoea.
The respiratory nurse team (RLN) provide a hospital based Tayside service, plus home
visiting for patients who have home oxygen therapy. The RLN service aims to provide
support and information to patients throughout their hospital journey, self management
strategies, whilst utilising all members of the multidisciplinary team to ensure that the
patients quality of life is maximised. The sleep service provides support and education
for patients who have obstructive sleep apnoea; this is a hospital based service.
The team will provide you with a timetable; however this is only a guide and can be
adapted to suit your learning experience.
LEARNING OBJECTIVES

To understand the respiratory patient pathway from pre-diagnosis onwards

To identify key members of the MDT team and their roles

To identify key investigations to diagnose respiratory and sleep conditions

To identify the symptoms of patients with respiratory conditions

To identify the importance of the extended multidisciplinary team, primary,
secondary and tertiary care; statutory and voluntary organisations in providing
care to respiratory patients

To identify and discuss the role of the most common treatments for respiratory
conditions and obstructive sleep apnoea

To identify the common psychosocial issues for patients with long term
respiratory conditions
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Indentified learning experience
Date completed (CNS initials)
RLN Service
Pulmonary Function
Pulmonary Rehabilitation
Nurse Led Oxygen Assessment Clinic
Ward referrals – AMU / Ward 3
Community COPD Nurses
Home visit
Sleep Service
Embelletta clinic
Embelletta – information review
Diagnostic clinic
Follow up clinic
Useful Websites
My Life My Lungs – Chest Heart and Stroke
http://www.chss.org.uk/chest-information-and-support/how-we-can-help/support-foryou/my-lungs-my-life/?gclid=CKHZp6jlqMkCFWQUwwodIQwHgA
Asthma UK
http://www.asthma.org.uk/?gclid=CIn1pcLlqMkCFRQTGwodSVkFmw
British Thoracic Society
https://www.brit-thoracic.org.uk/
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Section Four
Cystic Fibrosis Team
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CF INFORMATION BOOKLET FOR STUDENTS
Objectives for Student Nurses
At the end of this placement with the CF team, you should have a basic understanding and
awareness of the following –
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Incidence, prevalence and survival
Genetics
Clinical manifestations
Clinical symptoms
Pathology and treatment
Complications with increasing age
The need for specialist care – the role of the CF team
INTRODUCTION
Cystic Fibrosis is the most common recessively inherited disease of Caucasian populations,
with a carrier rate of 1 in 25 and an incidence of 1 in 2,500 live births.
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PATHOGENESIS

During the 1980’s 2 important findings changed our understanding of CF. The first group
of observation led to recognition that certain epithelial chloride channels and their
regulation are defective in tissues that express the CF phenotype, the second was the
identification, cloning and sequencing of the CF gene on the long arm of chromosome 7.

CF is the result of many mutations affecting a single point on chromosome 7 – coding for
the protein CFTR (cystic fibrosis transmembrane conductance regulator)
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This protein is responsible for the movement of chloride ions across cell membranes.

CFTR is expressed in epithelial cells particularly in the respiratory tract, GI tract, sweat
glands and pancreas
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The defect in CRTR results in reduced water content in the mucous of the respiratory
system.
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Sticky tenacious mucous accumulates – leading to obstruction of small air passages,
distal collapse and bacterial infection. Inflammatory bronchial damage, bronchiectasis
and death from respiratory failure may follow.
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In the liver and pancreas, blockage of secretory ducts results in atrophy and fibrosis.

Within the gut, the presence of thicker intestinal mucous can lead to reduced motility,
and dehydrated cell activity can lead to an intestinal obstruction within the distal loop of
the large bowel
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Diabetes mellitus and sinus disease develop as patients mature in age
Fertility problems can affect both males and females
Bone health and density are affected by absorption issues
DIAGNOSIS
CF is usually recognised in early childhood by the clinical features of (commonly) Cough,
loose stools and failure to thrive.
Confirmation involves positive sweat test, although sweat tests in unusual genotypes may
be the higher range of normal or normal, with the most accurate method of actual diagnosis
being blood screening / genetic profiling for specific CF mutations
Neonatal screening was introduced in Scotland on all babies from February 2003.
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With screening the mean age at diagnosis is 6 – 9 weeks.
Without screening, or for those who were born before routine screening was the norm,
diagnosis can come at any later stage in life, depending on symptoms and exposure to
appropriate respiratory specialists
CHANGING DEMOGRAPHY
The increasing number of patients with CF is mainly due to improved survival. In 1938 when
the disease was first described there was a 70% mortality rate in the first year of life.
Patients with CF born between 1968 and 1970 had a median survival of 18 for males and 15
for females. The survival rate of subsequent cohorts has clearly improved and if the trend
continues then patients born with CF today can expect a median survival of over 40 years.
The average age range of our patient group in Tayside is 26 years
MANAGEMENT OF RESPIRATORY DISEASE
Although CF affects many organs it is the respiratory tract which is associated with the most
significant morbidity and mortality. Lung damage occurs as a result of repeated infections
and the inflammatory sequel.
Therefore, the main aim of treatment is to maintain lung function by aggressive treatment
of infections.
COMMON PATHOGENS
Pseudomonas aeruginosa
– chronic infection (defined as persistent for 6 months or more, and/or development of a
significant antibody response) is by far the most important factor leading to excess
morbidity and mortality in CF.
Burkholderia cepacia
– does not cause infection in non-CF patients. The consequences of acquiring B Cepacia vary
from asymptomatic carriage to rapidly progressive clinical deterioration. Any patient found
to be growing B Cepacia must be isolated from other CF patients. We therefore use separate
lung function equipment and these patients are isolated at the clinic.
Non Mycobacterium Abscessus (NTM )
– an emerging problematic bacteria which is often multi resistant and requires protracted
courses of eradication antibiotics and other therapies
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Aspergillus fumigatus – may result in allergic bronchopulmonary aspergillosis ( ABPA )
– treated with prednisolone and itraconazole orally. Patients with persistent wheeze or
unexplained deterioration of lung function should be routinely tested for Aspergillus titres.
Staph Aureus – is normally the first bacteria to colonise the CF lung, and is generally present
in all of our patients
IV ACCESS
Patients attending our service use either a peripheral long line, picc line or an implantable
port for IV access. Where possible, we encourage patients to opt mostly for home treatment
and are taught administration techniques by the CF Nurse Specialist who then supervises
the course of therapy.
OTHER RESPIRATORY TREATMENTS
Bronchodilators
Corticosteriods
Dnase therapy
Mucolytics
Long term oxygen therapy
Non Invasive Ventilation (NIV)
LIVER DISEASE
Patients are screened in clinic for the presence of hepatosplenomegaly.
Liver function tests are performed annually at least and all patients shown to have impaired
liver function are commenced on Ursodeoxycholic acid. This drug can slow down or stop the
progression of chronic liver disease.
Patients with worsening liver disease should be screened for the presence of oesophageal
varices. CF patients with liver disease should avoid taking aspirin or related compounds.
Female patients with liver disease should avoid taking oral contraception.
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CF RELATED DIABETES
Incidence increases with age and occurs more frequently than in the general population.
The gradual development Of CF related diabetes is due to a slow loss of beta cells in the
pancreas. From the age of ten years, we screen all patients annually by using an oral glucose
tolerance test to detect the development of impaired glucose tolerance and CF related
diabetes
Oral hypoglycaemic agents are rarely used but most patients’ progress on to insulin, usually
once/twice per day, although four time’s daily regimes are not uncommon.
Patients with unexplained weight loss or deterioration of lung function should be
considered for glucose intolerance or diabetes.
Specialist dietary advice is also important, as, on a normal diabetic diet, the CF patient
would lose weight. The insulin regime is therefore adjusted to the meal and not the other
way round.
Patients with diabetes are reviewed in the CF and diabetic clinics.
FERTILITY
98% of male patients are infertile due to abnormal development of the vas deferens,
epididymis and seminal vesicles. Spermatogenesis still occurs so it is possible for IVF to be
performed.
In women with CF, fertility may be impaired due to changes in cervical mucous. However it
is possible for them to become pregnant. Particular attention must be given to nutrition and
pulmonary infections should be controlled. In the latter stages of pregnancy lung function is
reduced and physiotherapy positions may need to be modified.
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PSYCHOSOCIAL ISSUES
The advances in medical treatment of CF have increased life expectancy but it is also
important to optimise the quality of life. The requirements of adolescents and adults are
complex and the provision of psychosocial support is important.
The following areas are ones that often require the most support from the team:
Diagnosis
Adolescence and transition to adulthood
Employment
Relationships
Benefit advice
Deteriorating health
For further information and to arrange placement or shadow time please contact Lawrie
MacDougall CF CNS on extension 36552, or via hospital switchboard on Bleep 4854.
Reflection of Learning Experience
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Evaluation of this placement
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Reference: CF Trust Standards for Care,
( Online at cysticfibrosis.org.uk 2014 .)
Mobile Educational App : available on Google Playstore, or iBook Store as a free download
“ Cystic Fibrosis – A Pocket Guide “
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