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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