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RESPIRATORY SPECIALIST NURSES STUDENT RESOURCE BOOK NINEWELLS HOSPITAL 0 INDEX SECTION PAGE ONE- Introduction to Respiratory Specialist Nurse Team and Orientation 2 TWO- Lung Cancer Team 7 THREE- Respiratory Liaison Team 15 FOUR- Cystic Fibrosis Team 19 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 6 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. 7 LUNG CANCER CLINICAL NURSE SPECIALIST (CNS) SERVICE LEARNING RESOURCE PACK AIMS OF RESOURCE PACK: 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 8 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 9 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 10 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 11 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. T1 – Tumours less than or equal to 3 cm (1 ½ inches). T1a – Less than or equal to 2 cm. T1b – Greater than 2 cm but less than or equal to 3 cm. 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. T2b – Greater than 5 cm but less than or equal to 7 cm. 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 N1 – The tumour has spread to nearby nodes on the same side of the body. 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. M – Metastasis (Spread) to Other Regions M0 - The tumour has not spread to distant regions. M1a – The tumour has spread to the opposite lung, to the lung lining (malignant pleural effusion) or has formed nodules on the pleura. M1b – The tumour has spread to distant regions of the body, e.g. the brain or bone 12 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 12 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 13 Section Three Respiratory Liaison Team 14 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 15 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 16 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/ 17 Section Four Cystic Fibrosis Team 18 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 – 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. 19 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) 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 The defect in CRTR results in reduced water content in the mucous of the respiratory system. 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. 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 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. 20 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 21 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. 22 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. 23 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 24 Evaluation of this placement 25 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 “ 26