Download Workbook for Elective / alternative placement Neurosciences

Workbook for Student Nurses on Elective /
alternative specialist placement in
Neurosciences
This placement is for 3rd year students and is to be
undertaken prior to internship
Student’s Name _____________________
Placement commenced _______________
Placement completed ________________
November 2010
1
The Neurosciences Directorate cares for patients who have problems arising
in their nervous system. The aim of this placement is to provide students with
opportunities for participating in a broader range of neuroscience nursing
skills than may be experienced in a placement within just one area of
neurosciences. The placement involves working in a variety of Neuroscience
settings and situations outside of the ward areas. Although there is no
assessment on this placement the student is required to provide evidence of
attendance and to complete the worksheets as evidence of learning.
The four week placement encompasses
 Neurological condition specific specialist nurse shadowing
 Neuro rehabilitation
 Neuro investigations
 Observing the roles of Allied Health professionals.
 Neurosurgical pre operative assessment clinic
 Observation in Neuro interventions suite
There are a number of specialist nurses within the Neurosciences Directorate
whose work supports the delivery of Neuroscience services in order to meet
the requirements of the NSF for long term conditions. Most of the specialist
nurses work within the Neurology department but within Neurosurgery there
are specialist nurses for oncology, and a dedicated neurosurgical pre op clinic
is staffed by a sister in pre operative assessment.
You will not be allocated a specific mentor for the whole of the placement but
you will be given the name of a contact person in each area who will act as
your mentor during your time spent in that area.
Please note that some clinics are held on specific days only.
Name
Week 1
Week 2
Week 3
Week 4
NMD (Neuro
muscular
disease)
Glasshouse
clinic
MND (Motor
neurone
disease)
Care and
research
centre
Shadowing of
other
Neuroscience
specialist
nurses
Observations
of practice
and
shadowing of
specialist
nurses
Attended
Signed
2
Week 1
NMD Neuromuscular disease
Monday
Tuesday
Wednesday Thursday
‘Glasshouse ‘Glasshouse ‘Glasshouse Attend
Clinic’
Clinic’
Clinic’
Neurophysiology
Ward round
department
am
‘Glasshouse ‘Glasshouse ‘Glasshouse Potential home
Clinic’
Clinic’
Clinic’
visit
pm
Friday
Attend
Neurophysiology
department
General
Neurology Clinic
Peripheral
Nerve clinic
Attended
On Monday morning report at 08.00 to the Nurse in charge in the Glasshouse
clinic (off ward 2c)
Contact person Samantha Jones NMD Nurse specialist
Telephone
Aim
To develop an understanding of the aetiology of peripheral neuropathies, their
treatment, and patient management.
Objectives



Observe patient assessments carried out by the Consultant neurologist
and specialist nurse.
To understand the role of the specialist physiotherapy
To understand IVIG therapy.
Assist in the safe administration of IVIG by checking medication with
trained nurse, recording vital signs observations and VAD score, and
completion of relevant documentation.
Complete the knowledge questions incorporated in this workbook.
Personal objectives

___________________________________________________

____________________________________________________



Resources
The clinic provides care for patients with peripheral Neuropathies
attending for Intravenous immunoglobulin (IVIG) therapy as day attendee’s.
The Clinic space was funded by a generous donation from a patient. The
clinic is staffed with a nurse on rotation from the Neurology ward 17 supported
by the Specialist nurse for neuromuscular disease (NMD). The clinic can
accommodate six patients who are mobile and self-caring.
Day one
Orientation to the clinic
3
Emergency procedures discussed – location of resuscitation trolley/ phone.
Patient access to toilet facilities, on the adjacent ward.
Clinic routine
The clinic routine is described below
Preparation of patient
 On arrival the patient’s identity is confirmed and an ID wristband
applied.
 The patient is activated on the Quadramed system.
 The patient’s blood results are checked.
 The patient is assessed to determine whether they are fit for treatment
 The patient is then cannulated with their consent and bloods collected
if not done previously.
 Blood for serum save and IgA should have been collected prior to the
first dose of IVIG, which will have been delivered previously on the
neurology ward.
 The doctor is informed of any abnormal blood results.
 Vital signs are recorded - Temperature, pulse, blood pressure,
respiratory rate, EWS.
 Any abnormalities such as pyrexia or hypertensive are reported, as
treatment may need to be deferred.
 The patient’s prescription chart and availability of their medication is
checked.
 The patient’s weight is checked and the rate of infusion calculated as
per the manufacturers guidelines.
Treatment can then be commenced via a volumetric infusion pump.
 The batch number of the IVIG is recorded on the prescription chart
 The rate is increased ½ hourly until the maximum rate is achieved
 The observations are carried out with each rate increase, and on
completion of the infusion.
 The rate is adjusted and observations checked if the patient is
symptomatic.
 The nurse needs to ensure that the patient maintains a good oral fluid
input.
 When the infusion is complete Na Cl 50 mls is delivered as prescribed.
Lunch is arranged for the patient by printing a menu from the intranet and
sending to catering.
Follow up appointments is arranged in the diary.
Discharge
A summary is completed with a copy to GP.
An entry is made in the case notes of the episode of treatment including any
events and Doctors visits.
4
Medical staff
Most of the patients are under the care of Dr Nixon who will see the patients
on Monday morning. A small number of patients are under the care of Dr
Shaunak. There are no planned junior doctor visits.
MDT care
All patients with peripheral neuropathy must be seen, at least once a year, by
a Chiropodist.
A Physiotherapist regularly reviews patients.
Knowledge Questions
Diagram of a nerve cell (neurone).
Describe the following
Sensory nerve
______________________________________________________
Motor nerve
_____________________________________________________
The shaded areas around the neuron on the diagram above represent the
myelin sheath. What is the function of the myelin sheath?
______________________________________________________
5
Which neurological condition is caused by a disorder of the myelin sheath?
How would you describe peripheral neuropathy?
What are the causes of peripheral neuropathy?
What are the symptoms?
How is peripheral Neuropathy diagnosed?
How does immunoglobulin work?
What other treatments are currently available?
What ongoing tests / assessment are carried out and why?
How would a reaction to previous treatment manifest itself?
What would be the response to this?
6
What could be the possible reasons for a headache in a patient undergoing
treatment? What the nurse do about this?
Knowledge questions completed
Signed______________NMD Nurse Specialist
YES
NO
Date________
Reflection
What did you learn form this week?
How will this contribute to your future development as a nurse?
7
Week 2
MND Motor Neurone disease Care and Research centre
Monday
Report to
MND Centre
off Ward 17
Hospice
Clinic
Observe
process of
Riluzole
prescribing
am
pm
Tuesday
Observation
of research
activity
Wednesday
Hospice
Clinic
Thursday
Team
meeting
Friday
Hospice
clinic
Clinic
Respiratory
Clinic
Home visit
OT and
physio
MDT
Attended
On Monday morning report to the MND care centre at 08.30 located off Ward
17
Contact person Pauline Callagher Co ordinator
Telephone 4901
The above timetable is a rough guide only. Activities will be planned by the
Specialist nurses, according to the patient’s needs, during the week.
Aim
To develop an understanding of the disease process of MND and the care
and management of patients with this condition
Objectives
 Understand how a diagnosis of MND is made
 Be aware of the care needs of patients with MND including respiratory
management
 Be aware of the support needed and available for families and carers
 Be aware of end of life care, preferred place of care and preferred
priorities of care.
 Have an understanding of the current Research around MND.
 Be aware of the roles of the MDT
Personal objectives
 ________________________________________________

_________________________________________________
Resources
www.mndassociation.org/
National Institute for Health and Clinical excellence www.nice.org.uk
8
The MND Care and Research Centre covers the Catchment area of
Lancashire and South Cumbria, which has a population of approximately 1.7
million. Statistically, the incidence of MND in England and Wales is
approximately 2 cases per 100,00 people per year (similar to MS); due to the
rapid progression of MND the prevalence is only about 7 per 100,00
compared with about 50 per 100,000 people per year for MS. All patients
diagnosed with MND in the area are referred into the Care Centre. The needs
of the patient can be very intense, particularly in those with rapid progression
necessitating a quick response.
We have a small number of patients living outside the catchment area, i.e.
from Southport or Skipton.
The service provides advice and support to people living with MND, and their
carers, from the time they are suspected of having MND to death.
The nurse will perform a full assessment of limb strength and functional rating,
respiratory function, including spirometry and oxygen saturation monitoring.
Discussions on interventions such as PEG feeding or non invasive ventilation
are discussed early in the disease trajectory and patients are encouraged by
the nurses to make advanced care decisions and these can be documented
on a ‘Preferred Priorities of Care’ patient held document or an advanced
directive.
You will have the opportunity to observe the MND specialist nurse in a variety
of settings:
Nurse-led clinics are held in RPH on a weekly basis, there are also MDT
clinics held monthly were patients and carers can be seen by dietician,
occupational therapist, physiotherapist, speech and language therapist and
the MND nurse.
Due to the rapid progression of the disease patients are often unable to travel
to RPH from the wide catchment areas. The nurses hold 3 monthly clinics at
all of the hospices in the catchment area (St Mary’s, Ulverston; St John’s,
Lancaster; Trinity, Blackpool; St Catherine’s, Preston; East Lancashire
hospice and Pendleside Hospice in Burnley).
If the patients are unable to leave the house then home visits can be
arranged. There have been occasions where the nurses have been asked to
visit patients in hospitals to give advice whilst they were inpatients. The MND
nurses also hold a joint clinic with Dr Vyas, respiratory physician, to access
non-invasive ventilator services and specialist respiratory assessment.
A system for nurse led assessment for enteral feeding has been developed,
where the MND specialist nurses refer patients to the nutritional nurse
specialist for discussions with regard to PEG placement. Patients are then
fast tracked for admission to Ward 17 to undergo the procedure.
9
There is also the opportunity to observe MDT working in each primary health
care trust; there are special interest groups attended by community therapists,
palliative care teams and district nurses. These meetings occur 3 monthly in
each locality, the intention is to discuss each patient with others involved in
their care. This enables each professional to discuss issues or concerns they
may have with regard to the patients care and also updates the community
team on the patient’s condition and ensures all the health care professionals
present themselves as a ‘health care team’ to the patient, not individual health
care workers independent and uncommunicative of each other. These
meetings also provide support to the professionals involved in difficult and
distressing cases, perhaps in some cases acting as multi-professional clinical
supervision. The MND Care and Research Centre would also give the learner
a chance to observe the research activity many of which are supported and
assisted by DeNDRoN NW
1 European MND Register and Investigational studies (EURALS/ALSA)
This involves the patient agreeing for details of their illness to be recorded on
a European MND Register. Preston is the English Steering Centre and the
Register is coordinated from Milan in Italy. Subsequent amendments currently
include a questionnaire into Physical activity, sports and trauma in MND. No
patient identifiable data leave the Preston Centre however and all data on the
Register is in an anonymised form.
2 Optimisation of Patient Care in Motor Neurone Disease
This study is funded by the National Institute for Health Research coapplicants are Mary O’Brien, Prof Mitchell and Pauline Callagher. It seeks to
enable the design of improved care pathways for people with Motor Neurone
Disease through interviews between researchers and patients, their carers
and relatives.
3 MND DNA Biobank
This is a study funded by the Motor Neurone Disease Association and
adopted by DeNDRoN to generate a DNA resource for people with MND. It
involves a comprehensive questionnaire completed by the nurse and blood
samples from the patient and a control. The patient’s family are encouraged to
donate samples where appropriate
4 Early Life Experiences in MND
This is a questionnaire based case control epidemiological study examining
the important of early life and childhood experiences n relation to the
subsequent development of MND in adult life. This involves the person with
MND completing a short questionnaire, which should not take, more than 30
mins. Their spouse or partner also needs to complete the same
questionnaire as a case control.
5 Scales Study (Assessment and development of patient questionnaires
for use in MND).
10
Measurements of the severity of illnesses are often recorded giving potentially
useful information about the impact and response to treatment by asking
patients to complete questionnaires, scales or scoring systems. This study
involves testing the information obtained from a series of MND-related
questionnaires, which will be analysed using the latest statistical techniques.
This project is managed through the Walton Centre and Liverpool University,
Preston assists by providing patients the opportunity to participate and
provide assistance to the patient to complete the questionnaire where
necessary.
6 LicALS
The Preston Care and research centre will be one of ten care centres in the
UK to participate in a double blind randomised parallel group controlled trial to
evaluate the efficacy, safety and tolerability of lithium in MND plus standard
treatment, versus matched placebo plus standard treatment in patients with
ALS. The trial is funded by the MNDA and supported by staff from the care
centre and DeNDRoN.
Knowledge questions
How would you describe MND?
How is it diagnosed?
What is the therapeutic management?
How would you support respiratory function in a patient with MND?
11
What help is available for patients and their carers?
Reflection
What did you learn form this week?
How will this contribute to your future development as a nurse?
12
Week 3
Shadowing Specialist Nurses
am
Monday
Parkinson’s
disease
pm
Parkinson’s
disease
Tuesday
NRU
MDT
meeting
Wednesday
Epilepsy
Epilepsy
Thursday
Multiple
sclerosis
Clinic
Multiple
sclerosis
Friday
Dystonia
Clinic (off
Ward 2c)
Attended
Signature
of SN
On Monday Morning report to the office of the Parkinson’s disease nurse
specialists in block C.
Parkinson’s disease
Contact persons Nicola Mason and Rita Massey
Telephone 3575
Aim
Develop an understanding of the diagnosis, treatment and management of
patients with Parkinson’s disease.
Objectives
 To be aware of the NICE clinical guidelines on Parkinson’s disease
 To develop an awareness of the disease progression.
 To understand the importance of the timing of Parkinson’s medications.
Resources
Parkinson’s UK www.parkinsons.org.uk
National Institute for Health and Clinical excellence www.nice.org.uk
Knowledge questions
How would you describe Parkinson’s disease?
What are the primary symptoms of Parkinson’s disease?
13
What are the later symptoms of Parkinson’s disease?
How is the condition diagnosed?
What medical treatment is available?
How do these medications work?
Are there any other treatments?
Reflection
What did you learn from spending time with the Parkinson’s disease nurse
specialist?
How will this contribute to your future development as a nurse?
14
Neuro rehabilitation
On Tuesday morning report to the nurse in charge at the NRU on Watling
Street Rd.
Contact person Paul Topping Ward Manager
Telephone 01772524473
Aim
To develop an understanding of the aetiology of acquired brain injury and the
rehabilitation process
Objectives
 To observe the assessments undertaken for neuro rehabilitation
patients
 To gain an understanding of the roles of the MDT members
 To develop awareness of the support available for acquired brain injury
patients and how to access.
Resources
www.headway.org.uk
Rehabilitation following acquired brain injury National Clinical guidelines 2003
BSRM and RCP
NSF Long term conditions
Knowledge questions
How are patients referred to the NRU?
How would you define acquired brain injury?
What are the stages of rehabilitation?
What is the role of the key worker?
What assessment tools are used?
15
What is the role of family and carers?
Reflection
What did you learn from spending time at the NRU?
How will this contribute to your future development as a nurse?
16
Epilepsy
On Wednesday morning report to Leslie North in the Epilepsy specialist nurse
office in block c
Contact persons Leslie North, Stephanie Dixon, Epilepsy Nurse Specialists
Telephone 3132
Aim
To develop an understanding of epilepsy
Objectives
 To be aware of the NICE guidance on epilepsy.
 To develop and understanding of the types of epilepsy.
 To gain awareness of the different medications available and how they
work
 To develop an understanding of how epilepsy can impact on an
individual’s quality of life
Resources
National Institute for Health and Clinical excellence www.nice.org.uk
Knowledge questions
How is epilepsy diagnosed?
What are the main seizure types and how are the recognised?
What medical treatments are available?
Are there any other treatments available?
17
How and why does epilepsy affect an individual’s way of life?
What is the role of the Epilepsy nurse specialist?
Reflection
What did you learn from spending time with the Epilepsy nurse specialists?
How will this contribute to your future development as a nurse?
18
Multiple sclerosis (MS)
On Thursday morning report to the MS nurse specialist in the MS office on the
corridor adjacent to Charters restaurant. (Next to clinical audit)
Contact persons Monica Arthur, Angela Myerscough, Shirley Parkington
Telephone 3744
Aim
To develop an understanding of the disease process of multiple sclerosis, and
the care and management of this group of patients.
Objectives
 To be aware of NICE clinical guidelines
 To develop an understanding of disease modification therapies
 Develop an understanding of symptom management by observation in
the MS clinics
 Be aware of the advice available and given to individuals with MS
 Be aware of the support available for people with MS and how to
access.
Resources
MS society www.mssociety.org.uk
MS Trust www.mstrust.org.uk
National service frame works – NHS Choices www.nhs.uk/nhsengland
National Institute for Health and Clinical excellence www.nice.org.uk
Knowledge questions
How would you describe Multiple sclerosis?
How is the condition diagnosed?
What medical treatments are available?
How are the symptoms of the condition managed?
19
What is the role of the MS specialist nurse?
Reflection
What did you learn from spending time with the MS nurse specialists?
How will this contribute to your future development as a nurse?
20
Dystonia
On Friday morning report to the Dystonia clinic off Ward 2c
Contact person Sister Marianne King
Telephone 2656
Aim
To develop knowledge and understanding of Dystonia and the treatment
available
Objectives
 Understand the classifications of primary dystonia, aetiology, history
and epidemiology
 Identify the treatments on offer
 Understand the psychological and social difficulties experienced by
patients with Dystonia.
 Personal objectives
Knowledge questions
Provide a general brief overview of primary dystonia.
Describe the treatments on offer including drugs, surgery and alternative
therapies.
Describe Blepharospasm, aetiology, related anatomy and treatment.
Describe one other type of spasm, aetiology anatomy and treatment.
21
Describe the Psychological and sociological impact for patients with dystonia.
What sources of information are available to patients?
Reflection
What did you learn from spending time with the Dystonia nurse specialists?
How will this contribute to your future development as a nurse?
22
Week 4
Observation
am
pm
Monday
Neuro
Oncology
Clinic
(Off Ward
2c)
Neuro
Oncology
Clinic
Ward 2a/b
Tuesday
Pre op
clinic (Off
ward 2c)
Pre op
clinic
Wednesday
Observation
of coiling
(Neuro
interventions
suite)
Observation
of
neurosurgical
procedure
Thursday
Friday
Spinal cord
Neurophysiology
stimulation
(Off ward 2c)
Pain
management
Neurophysiology
Attended
Signature
SN
Neuro Oncology
On Monday morning report to Julie Law / Lorraine Rutlidge in the Oncology
Clinic off ward 2c
Contact person Julie Law Neuro Oncology Specialist Nurse
Telephone 3231
Aim
To develop an understanding of tumours of the nervous system and the
management of this group of patients
Objectives
 To develop an understanding of the different types of brain tumour
 To understand how diagnosis is made
 To develop an understanding of the ongoing management of the
patient with a brain tumour.
 To observe the MDT meeting
Resources
www.macmillan.org.uk
Knowledge questions
What types of tumour have you been made aware of?
23
What treatments are on offer?
What potential causes are there?
What is the role of the oncology nurse specialist?
Reflection
What did you learn form spending time with the oncology nurse specialists?
How will this contribute to your future development as a nurse?
24
Pre operative assessment Clinic
Report on Tuesday morning to Kim Ford / Tracy Shamsuddin in the Pre op
clinic located off ward 2c
Contact persons Sister Kim Ford / Staff Nurse Tracy Shamsuddin
Telephone 2656
The pre operative clinic provides a service four days a week for assessment
and optimisation of patients prior to undergoing Neurosurgery.
Aim
To develop an understanding of the process of pre operative assessment
Objectives
 To be aware of NICE guidance around pre operative assessment
 To be aware of the documentation to be completed
 To be aware of the risk factors for surgery and actions to be taken.
 Aware of situations where patients are referred back to their GP
Resources
Pre operative association www.pre-op.org
Institute for innovation and improvement www.institute.nhs.uk
Guidance on preoperative tests NICE www.nice.org.uk
Knowledge questions
What is the purpose of pre operative assessment?
When would a patient be deemed unfit for surgery?
What measures would be put in place to improve a patient’s fitness for
surgery?
What legal requirements are there in pre operative assessment?
What are the potential cost savings of pre operative assessment?
25
For how long is an MRSA swab valid?
Why is Aspirin discontinued prior to surgery?
What are the health promotion opportunities in the pre op clinic?
Reflection
What did you learn from spending time in the pre operative clinic?
How will this contribute to your future development as a nurse?
26
Neuro Intervention
Report on Wednesday morning at 09.00 to Steven Brown in the Neuro
intervention suite, lower ground floor of RPH.
Contact person Steven Brown
Telephone 4703
Aim
To develop an understanding of the rationale for neuro interventional
procedures and the process involved for the patient.
Objectives
 Revision of basic anatomy and physiology of the brain and spine
 Understand basic interpretation of head scans
 Understand the causes of intra cerebral bleeds
 Observe coiling of aneurysm of the brain
Resources
LTHTR Patient information booklet ‘Subarachnoid haemorrhage: Coiling of
cerebral aneurysms. A guide for patients and relatives.’
www.brainandspine.org.uk
Knowledge questions
Diagram to illustrate cerebral circulation.
Can you complete the diagram by indicating what the letters stand for?
ACA
AICA
MCA
ICA
PCA
PICA
27
AICA
BA
SCA
VA
ASA
What are the causes of intra cerebral bleeds?
What are the clinical signs that a patient may have had a subarachnoid
haemorrhage?
Name the different types of cerebral aneurysms.
Reflection
What did you learn from observing the coiling procedure?
How will this contribute to your future development as a nurse?
28
Spinal Cord stimulation
On Thursday morning report to Julie McLean at 08.30 on Ward 2b
Contact person Julie McLean Ward manager Ward 2b
Telephone 2713 or 8192
Aim
To develop an understanding of spinal cord stimulation
Objectives
 To be aware of the rationale for referral for spinal cord stimulation
 To observe the procedure
 To develop an understanding of the monitoring of patients with a spinal
cord stimulator.
 To understand the process of pain assessment in this group of
patients.
Resources
www.britishpainsociety.org
Knowledge questions
Why are patients referred for spinal cord stimulation?
What are the complications of this procedure?
How are these patients monitored following the procedure?
Reflection
What did you learn from spending time in the spinal cord stimulation clinic?
How will this contribute to your future development as a nurse?
29
Neurophysiology
On Friday morning report to Lesley Heggie in the Neurophysiology
department at the front of the hospital adjacent to the oncology department.
Contact person Lesley Heggie Clinical Physiologist.
Telephone 4418
Aim
To understand the neurological investigations that are carried out by the
department and their contribution to the diagnosis of neurological conditions.
Objectives






Observe nerve conduction studies
Observe EEG
Observe evoked potentials (Eps) in the diagnosis of MS
To observe Consultant Neurophysiologist
To develop an understanding of the investigations for peripheral nerve
entrapment
To understand the diagnostic tests for Carpel tunnel
Resources
British society for clinical Neurophysiology www.bscn.org.uk
Knowledge questions
What did you learn from spending time with Neurophysiology team?
How will this contribute to your future development as a nurse?
30
Placement evaluation and overall reflection of learning.
31