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FREEMAN HOSPITAL
PORTFOLIO OF LEARNING
OPPORTUNITIES
CORONARY CARE
(WARD 24/24A)
REVISED JUNE 2012 by Sister Debbie Bain
Added to Practice Placements, Northumbria University Website July 2012
1
CONTENTS
PAGE
INTRODUCTION
3
WARD PHILOSOPHY
4
LEARNING ZONE
5
KEY ELEMENTS
6
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INTERPERSONAL SKILLS
CLINICAL SKILLS
PATHOPHYSIOLOGICAL PROCESS
HEALTH DEVELOPMENT OPPORTUNITIES
MANAGEMENT OF CARE
ORGANISATIONAL AND MANAGERIAL ISSUES
THE HEART
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11
ANATOMY AND PHYSIOLOGY
THE CONDUCTION SYSTEM
THE ECG
HEART RATE “READY RECKONER”
ISCHAEMIC HEART DISEASE
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15
ANGIOGRAPHY
ANGIOPLASTY (UNSTABLE / PPCI)
CABG
SECONDARY PREVENTION (MEDICATION / REHAB)
AORTIC STENOSIS
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21
TAVI
AORTIC VALVE REPLACEMENT
HEART FAILURE
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26
ACUTE (MANAGEMENT – MEDICATION / CPAP)
CHRONIC (MANAGEMENT – MEDICATION / FLUID BALANCE / DIET)
MEWS / OBSERVATIONS
29
PACEMAKER
31
IMPLANTABLE CARDIOVERTER DEFIBRILLATOR (ICD)
33
ELECTROPHYSIOLOGICAL STUDIES / RADIOFREQUENCY ABLATION
34
COMMON ABBREVIATIONS
35
STUDENT NURSE CHECKLIST
40
Added to Practice Placements, Northumbria University Website July 2012
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INTRODUCTION
Ward 24/24a are situated on the ground floor of the cardiothoracic block at the Freeman
Hospital. You enter via Ward 24; this is our step-down cardiology ward and comprises of 3
six bedded bays and 3 cubicles. Ward 24a is at the top of the ward; this is our Coronary Care
Unit and comprises of 1 four bedded bay and 4 cubicles. You will notice there is direct
access to the unit via an emergency entrance.
This is for paramedic crew only.
The unit is a tertiary referral unit; we take direct admissions from all over the North East of
England for patients who are having a heart attack and need Primary Angioplasty to open the
blocked Coronary Artery causing the acute event. We also take other unstable cardiology
patients from all over the UK and Ireland, who may have electrical problems or need heart
failure management or surgery (Coronary artery bypass grafts, Valve repair / replacement /
TAVI, transplant / Ventricular Assisted Devices). As a student this is a great opportunity to
care for a wide variety of patients through their pathway from admission to discharge and
see how they are managed and treat.
Our staff is split into 2 teams which rotate between the ward and unit on a 2 weekly basis.
You will be allocated a Mentor and Co-Mentor prior to you arriving. If this is your final
placement one of them will be a sign off mentor (or be supervised by one). Ward staff
welcome the opportunity for students to come for a pre-placement visit and this is possibly
an opportunity to meet your mentor or associate mentor.
We know our area may seem a bit intimidating at first, but
the staff are there to support you. It is really important that
you feel you can share your concerns with us and don’t just
bottle them up.
We take a multi-disciplinary approach to patient care given
on ward 24/24a. During your time on the ward there will be
opportunity to liaise / work with the other members of the team. These are outlined in the
learning zone and will help you meet your clinical competencies. If there is someone on the
list you are really interested in working with or something you really want to see within our
area, let us know early in your placement and we will see what we can organise for you. We
want the experience to be as full and enjoyable as possible for you.
We have a variety of shift patterns; we would expect you to be able to rotate alongside your
mentor.
Early 07:15 – 15:25 Late 12:55 – 20:45 Long Day 07:15- 20:45
Nightshift 20:20-07:45
NURSING PHILOSOPHY
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Our aim is to provide nursing care of the highest
standard, taking into consideration the patients
physical, social and psychological needs. We
understand that patient’s moods may be
influenced by their clinical condition and
physical environment.
Let’s face it this isn’t like sitting at home with a
coffee, most of what our patients go through is
pretty scary stuff!!
We hope to change the negative aspects of illness into positive attitudes, so
promoting a healthier lifestyle both in hospital and after discharge.
Our belief is that health is not just the absence of disease. Dubos (1960)
sees “health as the adaption to change in nature and society”.
The World Health Organisation (WHO) defines health as:
LEARNING ZONE
Added to Practice Placements, Northumbria University Website July 2012
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LUNG
FUNCTION
CARDIO
THEATRES
AND CATH
LABS
XRAY
(CT AND
MRI)
CARDIO
ITU
WARD 26
&
OUTREACH
mps
CARDIAC
REHAB
&
SMOKING
CESSATIO
N
ECHO
ECG
PACING
TECHNICIANS
CORONARY
CARE
(24A)
&
WARD 24
PALLIATIVE
CARE
PAIN
CONTROL
TEAM
DIABETIC
TEAM
&
DIETICIAN
PHARMACY
PHYSIO
OT
TRANSPLAN
T
TEAM
SOCIAL
WORKER
OTHER
SPECIALTIE
S
RENAL
STROKE
GASTRIC
LIBRARY
INTERNET
ELEARNING
AND MORE……………
KEY ELEMENT: INTERPERSONAL SKILLS
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LEARNING OPPORTUNITIES
USE OF THE TELEPHONE
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MAKING / ANSWERING CALLS
RING BACK
TRANSFERRING CALLS
TEAM MEMBER WHO
CAN PROVIDE
LEARNING
OPPORTUNITIES
WARD CLERK
NURSES
USE OF THE COMPUTER
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E-RECORD / PATIENT DATA
ADMIT / DISCHARGE / TRANSFER PATIENT
ORDERING SPECIMENS
OBTAINING BLOOD / SPECIMEN RESULTS
PATIENT ALLERGIES DOCUMENTED
GIVING PRESCRIBED MEDICATION
MEDICATION INFORMATION
ORDERING MEDICATION
ORDERING INVESTIGATIONS
OTHER MDT REFERALS
INTERNET / INTRANET / LEARNING PORTAL
E-LEARNING ZONES
POLICIES, PROCEDURES, DATIX etc…
SEPARATE REFERAL SYSTEM (from other hospitals)
E-MAIL ACCESS
CARDIAC REHAB FORMS
COMMUNICATION with : PATIENTS
 RELATIVES
 MEDICAL STAFF
 NURSING STAFF
 HEALTHCARE
 DOMESTICS / HOUSEKEEPER
 PHSIOTHERAPY
 OCCUPATIONAL THERAPY
 SOCIAL WORKERS
 CARDIAC REHAB TEAM
 SMOKING CESSATION
 HEART FAILURE AND BRITISH HEART
FOUDATION NURSES
 DIETICIAN
 PHARMACY
 DISTRICT NURSES
 OUTREACH AND OTHER SPECIALIST NURSES
WARD CLERK
NURSES
IT DEPARTMENT 21000
DOCTORS
NURSES
HCA
DOCTORS
OTHER MEMBERS OF THE
MULTI DISCIPLINARY TEAM
SPECIALIST NURSES
KEY ELEMENT: CLINICAL SKILLS
Added to Practice Placements, Northumbria University Website July 2012
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LEARNING OPPORTUNITIES
PATIENT HYGIENE
MOUTH CARE
SKIN CARE
PRESSURE AREA CARE (BRADEN SCORE)
ASEPTIC NON TOUCH TECHNIQUE (ANTT)
TEAM MEMBER WHO
CAN PROVIDE
LEARNING
OPPORTUNITIES
NURSES
TISSUE VIABILITY
INFECTION CONTROL
INTRANET
E-LEARNING
RECORDING OF PHSIOLOGICAL OBSERVATIONS
MEWS SCORE
AVPU SCORE
BLOOD PRESSURE
TEMPERATURE
RESPIRATION RATE
OXYGENS SATURATIONS
URINE OUTPUT / FLUID BALANCE
INVASIVE MONITORING (CVP MEASUREMENTS)
SAFETY CHECKS
FEMORAL / RADIAL SITE OBSERVATIONS
BALLOON PUMP OBSERVATIONS / RATIO
CPAP SETTINGS
TEMPORARY PACEMAKER SETTINGS
URINALYSIS
FOB TESTING
BLOOD GLUCOSE
HEIGHT / WEIGHT / BMI
DIETARY INFORMATION / FOOD CHART
RECORDING OF AN ECG
OUTREACH NURSE
NURSES
DOCTORS
TECHNICIANS
ECG DEPARTMENT
DIETICIAN
DIABETIC NURSE
DRUG ADMINISTRATION
E-RECORD (DRUG ADMINISTRATION CHARTS)
ORAL
INTRA MUSCULAR (IM)
SUBCUTANEOUS (S/C)
INTRA VENOUS (IV) BOLUS AND/OR INFUSIONS
RECTAL
SUB LINGUAL
BUCCAL
CANNULATION (SEE VIP CHART)
CARE OF CENTRAL LINES / ARTERIAL LINES (SEE CHART)
LONG LINE (SEE CHART)
ADMINISTRATION OF BLOOD AND BLOOD PRODUCTS
PATIENT IDENTIFICATION AS PER POLICY
NURSES
DOCTORS
PHARMACISTS
BNF / INTRANET
TRUST POLICES
PROCEDURES
INFECTION CONTROL
TRANSFUSION
KEY ELEMENT: PATHOPHYSIOLOGICAL PROCESSES
Added to Practice Placements, Northumbria University Website July 2012
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LEARNING OPPORTUNITIES
TEAM MEMBER
WHO CAN PROVIDE
LEARNING
OPPORTUNITIES
CARDIOVASCULAR SYSTEM
ANATOMY AND PHYSIOLOGY OF THE HEART
ISCHAEMIC HEART DISEASE
STABLE ANGINA
ACUTE CORONARY SYNDROME:
 UNSTABLE ANGINA (TROPONIN NEGATIVE)
 NSTEMI (NON ST ELEVATION MYOCARDIAL INFARCTION)
 STEMI (ST ELEVATION MYOCARDIAL INFARCTION)
CARDIAC ARREST
CARDIAC ARRHYTHMIA’S: ATRIAL FIBRILLATION (AF)
 ATRIAL FLUTTER
 VENTRICULAR FIBRILLATION (VF)
 VENTRICULAR TACHYCARDIA (VT)
HEART FAILURE
HYPERTENSION
CARDIOMYOPATHIES
CARDIAC TAMPONADE
RECORDING OF ECG’S
CARDIAC MONITORING
EXERCISE TOLERENCE TEST (ETT)
MIBI SCANS
TRANSOESOPHAGEAL ECHOCARDIOGRAPHY (TOE)
ECHOCARDIOGRAPHY (ECHO)
ANGIOGRAM
PERCUTANEOUS INTERVENTION (PCI)
PRIMARY PERCUTANEOUS INTERVENTION (PPCI)
CORONARY ARTERY BYPAS GRAFTS (CABG)
TRANS-CATHETER AORTIC VALVE IMPLANTATION (TAVI)
ELECTROPHYSIOLOGY STUDIES (EPs)
RADIOFREQUENCY ABLATION (RFA)
D.C. CARDIOVERSION
EXTERNAL PACING
TEMPORARY PACEMAKER INSERTION
PERMANENT PACEMAKER INSERTION
INTERNAL CARDIAC DEFIBRILATOR (ICD)
Biventricular PACEMAKER / ICD
NON-INVASIVE VENTILATION (NIV)
 CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
BOOKS
NURSES
DOCTORS
CARDIAC ARREST TEAM
OUTREACH
PACING TECHNICIANS
MEDICAL PHYSICS
DEPARTMENT
ECHO DEPARTMENT
CATH LABS
WARD 26 (ITU)
KEY ELEMENT: HEALTH DEVELOPMENT OPPORTUNITIES
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TEAM MEMBER WHO CAN
PROVIDE LEARNING
OPPORTUNITIES
LEARNING OPPORTUNITIES
HEALTHY LIFESTYLE / HEALTH
PROMOTION STRATEGIES.
SMOKING CESSATION
OBESITY / CHOLESTEROL
DIABETES
HEALTHY EATING
ALCOHOL
PROMOTION OF EXERCISE
CARDIAC REHABILITATION
COMMUNITY REHABILITATION
HEART MANUAL
COUNSELLING
NURSES
DOCTORS
SMOKING CESSATION NURSE SPECIALIST
DIETICIAN
DIABETES NURSES
PHYSIOTHERAPISTS
CARDIAC REHAB SPECIALIST NURSE
COUNCILORS
MANAGEMENT OF CARE
TEAM MEMBER WHO CAN
PROVIDE LEARNING
OPPORTUNITIES
LEARNING OPPORTUNITIES
NURSING PROCESS
ASSESSMENT
PLANNING / PRIORITISING CARE
CARE PLANS
RISK ASSESSMENT TOOLS
WARD ROUNDS
DOCUMENTATION
POLICIES / PROTOCOLS
MULTIDISCIPLINARY TEAM REFERRALS
DISCHARGE PLANNING
SELF DISCHARGE
DECEASED PATIENTS
RELIGIOUS AND CULTURAL NEEDS
PATIENT PROPERTY / VALUABLES
NURSES
DOCTORS
POLICY AND PROCEDURE FILES
O.Ts, PHYSIO’S, SOCIAL WORKERS
DISCHARGE LOUNGE
AMBULANCE SERVICES
RELATIVES
BEREAVEMENT OFFICER
HOSPITAL CHAPLAIN / PRIEST
PALLIATIVE CARE TEAM
KEY ELEMENT: ORGANISATIONAL AND MANAGERIAL ISSUES
Added to Practice Placements, Northumbria University Website July 2012
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TEAM MEMBER WHO CAN
PROVIDE LEARNING
OPPORTUNITIES
LEARNING OPPORTUNITIES
MANAGING A TEAM
ORGANISATIONAL SKILLS
DELEGATION SKILLS
PRIORITISING SKILLS
TIME MANGEMENT
MANAGING A PATIENT WORKLOAD
QUALITY
STANDARDS OF CARE
NURSES
SISTER / CHARGE NURSE
AUDIT TOOLS
MANAGING RESOURCES
NURSES
SISTER / CHARGE NURSE / MATRON
PHARMACY
STORES
HOUSEKEEPER
STOCK CONTROL
DRUG ORDERING
BUDGET CONTROL
SKILL MIX
RISK MANAGEMENT
POLICIES AND PROCEDURES
EQUIPTMENT SAFETY CHECKS
DATIX
REPORTING ACCIDENTS & INCIDENTS
INFECTION CONTROL
BARRIER NURSING
MOVING AND HANDLING / USE OF AIDS
PATIENT FALLS ASSESMENT
PRESSURE AREA ASESSMENT
NURSES / SISTER / CHARGE NURSE
POLICIES AND PROCEDURES (INTRANET)
HEALTH AND SAFETY OFFICER
INFECTION CONTROL
MEDICAL ELECTRONICS DEPARTMENT
MOVING AND HANDLING TEAM / LINK
TISSUE VIABILITY TEAM / LINK
EMERGENCY SITUATIONS
CARDIAC AREST TEAM 2222
FIRE 333
SECURITY 333
PORTERS 31753
OUTREACH 48817
CARDIAC ARREST
FIRE
SECURITY ALERT
THE HEART
Anatomy and Physiology
Added to Practice Placements, Northumbria University Website July 2012
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The heart is a muscular organ about the size of your fist, which pumps blood around the body.
It is very strong as it has to beat every hour of every minute of every day, contracting then
relaxing. Like any other muscle it needs its own blood supply in order to pump. These are
called coronary arteries and coronary veins.
The heart is divided into 4 chambers (the atria) receive blood coming into the heart. The atria
then deliver blood to the lower chambers (the ventricles) which pump blood away from the
heart.
The right side of the heart receives de-oxygenated blood from the various regions of the body
via the superior and inferior vena cava.
These two veins empty de-oxygenated blood into the right
atrium of the heart.
The sinoatrial node sends an impulse that causes the cardiac
muscle tissue of the atrium to contract in a coordinated
manner. The tricuspid valve, which separates the right atrium
from the right ventricle, opens to allow the de-oxygenated
blood to flow into the right ventricle. During this time the
pulmonary valve leading to the pulmonary artery is closed
allowing the right ventricle to fill with blood. Once the
ventricles are full, they contract. As the right ventricle
contracts the tricuspid valve closes and the pulmonary valve
opens. The closure of the tricuspid valve prevents blood from
backing into the pulmonary artery towards the lungs.
The left atrium receives oxygenated
blood from the lungs through the
pulmonary vein. As the contraction
progresses through the atria, the blood
passes through the mitral valve into the
left ventricle. The aortic valve leading
into the aorta is closed, allowing the
ventricle to fill with blood. One the
ventricles are full they contract. As the
left ventricle contracts the mitral valve
closes and the aortic valve opens
allowing oxygen rich blood to flow into
the aorta and to the rest of the body.
THE HEART
The Conduction System
The Electrical events in the cardiac cycle coordinate Atrial and Ventricular systole and
diastole. The heart has its own natural pacemakers; these are specialised muscle cells
responsible for initiating and conducting electrical impulses and are known as the
conduction system. In the normal heart, the cells of the conduction system are
Added to Practice Placements, Northumbria University Website July 2012
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interconnected, an electrical impulse (action potential) appearing at one location is
conducted across the entire network. In an adult a normal heart rate can range between 60100 beats per minute, when initiated from the SA Node. If there was a problem with this
pacemaker the next fastest pacemaker kicks in (AV node), followed by the bundle branches
and finally the purkinje fibres. At this point the rate will be nearer 30 – 40bpm.
The wave of depolarisation travels
from the SA Node, across the atria to
the AV node. Atrial depolarisation is
recorded on the ECG as the P Wave
and lasts about 0.08 seconds. The
atria contract approximately 0.1 s
after the P Wave begins.
A slight delay in transmission occurs
as the impulse passes through the
AV node. The magnitude of the
current through the AV node is too
small to be detected and is recorded
as an isoelectric line.
The QRS complex reflects the
depolarisation of the ventricles
through the Bundle of His, bundle
branches and Purkinje fibres. The
average duration of the QRS is
0.08s. The ventricles begin
contracting shortly after the peak of
the R Wave
Following ventricular depolarisation there is a short pause when the ventricles are refractory
(unable to accept further stimulation). This is recorded on the ECG as an isoelectric line. The
ventricles then repolarise, reflected as the T wave.
The Conduction System and the ECG
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DON’T FORGET TO LOOK AT YOUR PATIENT
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Ischaemic Heart Disease
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Ischaemic heart disease is defined as a narrowing in the arteries caused by fatty deposits
(known as plaque) lining the inside of the artery. This causes the muscle to become starved
of oxygen and generally results in chest pain (often referred to as angina) and/or
breathlessness. This is more common in the older population although we have had patients
as young as their early 20s admitted to our unit.
There are different types of angina. Stable angina
is when the patient experiences symptoms during
exertion i.e. physical activity. Unstable angina
occurs when the patient is resting; at this point they
are at high risk of having a heart attack.
Another term used is Acute Coronary Syndrome
(ACS). This is a blanket term and also includes
patients who have had a heart attack (Myocardial
Infarction – MI). This is where the plaque has
ruptured, causing a clot to form in the artery. This
may partially occlude it (known as a NSTEMI) or
fully occlude it (known as a STEMI).
Depending which category the patient falls into will dictate the type and urgency of
treatment the patient requires. Within our unit we admit patients who are unstable (via their
District General hospital’s Coronary Care or Cardiology Ward), either with unstable angina
or after a NSTEMI. We also admit patient’s directly or via Accident and Emergency if they
are having a STEMI).
To diagnose this we will use a combination of an ECG (sent to our monitors by the
paramedics) or faxed and take a full assessment of the patient (including their past medical
history and presenting symptoms). One of our Sisters will then decide where the patient
needs to go for their treatment.
The gold standard treatment for patients who
are blocking (occluding) their artery is called
a Primary Percutaneous Intervention (PPCI)
or otherwise known as Primary Angioplasty.
This has predominantly replaced
Thrombolysis, which is where patients were
given a very strong clot busting drug to
dissolve the clot. Not only did this method
carry higher risk of stroke and death it also
did not treat the underlying cause (the
plaque).
Angiography
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Angiography is a diagnostic procedure, which with the use of contrast dye and imaging
equipment allows the coronary arteries to be viewed. Any blockages are identified and if
possible opened. This is done under local anaesthetic (patient is fully awake) in the cardiac
catheter Labs – which is situated at the end of our ward. You are more than welcome to
follow the patient pathway and observe their procedure. This provides a greater
understanding of the procedure, the coronary arteries and also enables you to address patient
questions concerns and talk them through the procedure itself.
(All images obtained via Google image search engine)
The operator will let us know in advance if the patient is going for diagnostic angios only. If
not we assume that the operator will proceed to angioplasty and prep the patient for this.
None of our patients are starved for this procedure, although the area they are going to work
through (either the radial or femoral artery) may or may not be shaved depending on the
preference of the consultant. All patients will receive a loading dose of Clopidogrel 600mg,
which is our local policy, national guidelines currently still state 300mg. If the patient has
only had the lower dose of 300mg (over 24 hours prior to procedure), we will reload them.
If the patient has occluded the vessel (STEMI) they are given a loading dose of Prasugrel
60mg instead of Clopidogrel (providing there are no contra indications).
If the narrowing is too heavily calcified (too hard), considered to be too high risk to
angioplasty or there are too many narrowings, the patient may be considered for Coronary
Artery Bypass Grafts (CABG). The consultant will then discuss this and show the angiogram
to a surgeon and they will decide what are the safest treatment / operation for the patient.
Angioplasty / Percutaneous intervention (PCI)
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This is similar to an angiogram
with the same techniques used, but
it does however take it one step
further. The catheter used has a
balloon on the end of it.
Usually this is used in conjunction
with a stent, which is already
insitu around the balloon. The size
depends on how wide the artery is
and how long the plaque is and
where it is.
The stents are used to keep the artery open and therefore
improve blood flow. They are made of mesh and may or
may not be impregnated with drugs. The operator inflates
the balloon to position the stent firmly against the wall of
the artery. Then deflates the balloon and removes it,
leaving the stent in place.
The approach may vary depending on the consultant and if they have previously had CABG.
In most cases the radial artery is used, they will remove the sheath (tube they work through
in the artery) and apply a small pressurised band around the wrist which will be removed
gradually (once there is no sign of bleeding at the site). This means when the patient returns
they can sit up as soon as they return from the labs and are able to mobilise much earlier. If
they have gone femorally the patient will come back with the sheath insitu and ill have to lie
flat for approximately 6 hours. The patient will have received heparin in the labs to thin the
blood; therefore an APTR is performed (blood test to check the thickness of the blood) four
hours after the heparin has been given. The sheath will be taken out my one of the nursing
staff when the result is less than 1.2 and the systolic blood pressure is lower than 150mmHg.
It is important that they keep the leg with the sheath in straight so that no damage to the
artery is caused.
On return from the labs we take an ECG and check the patient’s observations. If they have
gone femorally we will check the site for any oozing or swelling. We also record to say if
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foot pulses are present and if the limb is warm and well perfused (colour – pale, mottled,
pink). Any concerns would be reported to a medic immediately and the sheath may need to
come out sooner rather than later.
If they go radially we will check both the radial and
ulna pulses below the TR band. Make sure that the hand
is warm and well perfused and check the patient can
move his / her fingers. Any sign of pain or numbness
may also indicate we need to release some air out of the
balloon in the TR band.
If the patient is unsuitable for angioplasty and needs CABG this will involve them going for
major open heart surgery. The idea is to restore blood flow to the heart by totally bypassing
the blockage using a vein from the leg or artery from the wall of the chest (Internal
Mammary Artery). They will need to go to Intensive Care (Ward 26) afterwards for 24-48
hours and then onto a cardiothoracic surgical ward to recover (Ward 25 or 30) for 4-5days
prior to discharge.
Secondary Prevention
This is geared towards reducing the risk factors that caused the patient to be admitted in the
first place. The patient is given a combination of medication and cardiac rehab.
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Medication
The discharge medication list usually consists of:Aspirin 75mg once daily, with food (anti-coagulant – blood thinner).
Clopidogrel 75mg or Prasugrel 10mg once daily, usually for 12 months (blood thinner).
Beta-Blocker usually Bisoprolol, if not contra-indicated (anti-hypertensive and anti-arrhythmic
properties).
ACE Inhibitor usually Ramipril (anti-hypertensive, preserves LV function and prevents cardiovascular
events).
Statin usually Atorvastatin (reduces cholesterol)
Cardiac Rehab
Phase 1
Inpatient Phase
 Robust referral process from CCU, wards, A&E, tertiary centres and rapid access
chest pain clinic.
 Transfer or information by fax, electronic means and first class postage
 Common referral form for rehab services
 Tracking systems in place to identify and locate patients in journey
 Advertising rehab services through our appropriate wards and hospital
 Hand held records
 Use of educational materials: books, tapes, videos, CD-ROM
 Information pack on medical ward
 Dietary information in leaflet form
 Cardiac chest pain at home management
 Training sessions for ward staff delivering post event education
 Direct referral to smoking cessation from rehab nurses
 Running carer’s support group
 Rehab nurses contacting patient’s GP to inform of admission
 Direct booking of exercise tolerance test and exercise class
Phase 2
Primary Care based
 4 day follow up done by community nurses
 Rehab nurses able to make direct named contact to a community nurse using a
database
 Named practise nurse
 Discharge letter sent to both district nurse and GP
 Use of Heart Manual
 Rehabilitation information pack held in GP surgeries
 Systems to identify follow up of revascularisation patients from tertiary centres
 Dedicated help lines for patients
 Follow up process for non-English speaking patients
Phase 3
Formal exercise and education programme
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Referral criteria assessed to allow disadvantaged patients to attend
Inclusion of other CHD patients into the programme
“Did Not Attend” (DNA) list maintained and GP informed after 3 misses
Audit of DNA’s exercise booklet for use at home
Exercise booklet for use at home
Introduction of shuttle tests
Borg rating scale of perceived exertion (RPE) scales displayed
Patient group directive (PGD) developed
Dietician Input
Demand and capacity exercise
Waiting list blitz
Phase 4
Long term maintenance and risk modification
 Annual patient reviews done in primary care
 Patient satisfaction surveys to identify issues for action
 Annual audit of services
 Patient and carer support groups
 Support group newsletter
 Walking for health
 Phase IV rehab
AORTIC VALVE DISEASE
(ANDY NARCROSS 2008)
The two main aortic valve diseases are aortic stenosis and aortic regurgitation. Aortic valves
can become thick and narrowed (stenotic), causing them not to open fully, or curled at the
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edges and leaky (aortic valve regurgitation or insufficiency), resulting in a backflow of blood
into the left ventricle.
AORTIC STENOSIS
Aortic valve stenosis (AS) is a valvular heart disease caused by the incomplete opening of
the aortic valve, or aortic stenosis, often abbreviated AS.
The aortic valve controls the direction of blood flow from the left ventricle to the aorta.
When in good working order, the aortic valve does not impede the flow of blood between
these two spaces. Under some circumstances, the aortic valve becomes narrower than
normal, impeding the flow of blood. This is known as aortic stenosis
Etiology
Major causes and predisposing conditions of aortic stenosis include acute rheumatic fever
and bicuspid aortic valve. As individuals age, calcification of the aortic valve may occur and
result in stenosis. This is especially
likely to occur in people with a
bicuspid aortic valve, but also occurs
in the setting of perfectly normal
valves as a result of age-induced
'wear and tear'. Typically, aortic
stenosis due to calcification of a
bicuspid valve occurs in the 4th or 5th
decade of life, whereas that due to
calcification of a normal valve tends
to occur later - around the 7th or 8th
decade.
Symptoms of aortic stenosis
When symptomatic, aortic stenosis can cause dizziness, syncope, angina and congestive
heart failure. More symptoms indicate a worse prognosis. Treatment requires replacement of
the diseased valve with an artificial heart valve.
Congestive heart failure
Congestive heart failure (CHF) carries a grave prognosis in patients with AS. Patients with
CHF that is attributed to AS have a 2 year mortality rate of 50%, if the aortic valve is not
replaced.
CHF in the setting of AS is due to a combination of systolic dysfunction (a decrease in the
ejection fraction) and diastolic dysfunction (elevated filling pressure of the LV).
Syncope
Syncope (fainting spells) in the setting of heart failure increases the risk of death. In patients
with syncope, the 3 year mortality rate is 50%, if the aortic valve is not replaced.
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Finally, in calcific aortic stenosis at least, the calcification in and around the aortic valve can
progress and extend to involve the electrical conduction system of the heart. If that occurs,
the result may be heart block - a potentially lethal condition of which syncope may be a
symptom.
Angina
Angina in the setting of heart failure also increases the risk of death. In patients with angina,
the 5 year mortality rate is 50%, if the aortic valve is not replaced.
AORTIC REGURGITATION
Aortic regurgitation (AR), is the leaking of the aortic valve of the heart that causes blood to
flow in the reverse direction during ventricular diastole, from the aorta into the left ventricle.
Aortic regurgitation can be due to abnormalities of either the aortic valve or the aortic root
(the beginning of the aorta).
Etiology
About half of the cases of aortic insufficiency are due to the aortic root dilatation which is
idiopathic in over 80% of cases, but otherwise occurs with aging and hypertension, Marfan
syndrome, aortic dissection, and syphilis. In about 15% the cause is innate bicuspid aortic
valve, while another 15% cases are due to retraction of the cusps as part of postinflammatory processes of endocarditis in rheumatic fever and various collagen vascular
diseases.
Acute Aortic regurgitation
In acute AR, as may be seen with acute perforation of the aortic valve due to endocarditis,
there will be a sudden increase in the volume of blood in the left ventricle. The ventricle is
unable to deal with the sudden change in volume.
In terms of the Frank-Starling curve, (The ability of the heart to change its force of
contraction and therefore stroke volume in response to changes in venous return) the enddiastolic volume will be very high, such that further increases in volume result in less and
less efficient contraction. The filling pressure of the left ventricle will increase. This causes
pressure in the left atrium to rise, and the individual will develop pulmonary edema.
Severe acute Aortic regurgitation is considered a medical emergency. There is a high
mortality rate if the individual does not undergo immediate surgery for aortic valve
replacement. If the acute AR is due to aortic valve endocarditis, there is a risk that the new
valve may become seeded with bacteria. However, this risk is small.
Acute AR usually presents as florid congestive heart failure, and will not have any of the signs
associated with chronic AR since the left ventricle had not yet developed the eccentric hypertrophy and
dilatation that allow an increased stroke volume, which in turn cause bounding peripheral pulses.
TAVI (Transcatheter Aortic Valve Implantation)
Information for Patients
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Your doctors are treating you for a condition called aortic stenosis. This is where the main valve
which allows blood to flow from the heart around the body has become narrowed. This may lead
to symptoms of chest pain or discomfort, breathlessness or black-outs. As the valve narrowing
worsens, this can cause weakening of the heart muscle’s pumping action (sometimes known as
heart failure) and may become a life threatening problem with time.
What causes aortic stenosis?
In most cases, aortic stenosis is due to a wear and tear process and is more common with age. In
some cases, the valve has been abnormal since birth and becomes more narrowed or leaky over
time. The valve may also become abnormal due to other conditions such as rheumatic fever.
Can aortic stenosis be treated?
If the valve is not severely narrowed, no specific treatment is needed and patients will usually be
offered routine check up appointments in the cardiology clinic to keep an eye on the valve.
If the valve problem becomes worse, there are three main options:
1. The most common treatment is called conventional open heart surgery, where the
narrowed valve is removed and replaced with an artificial valve. During this conventional
surgery, a cut through the breastbone is made to open up the chest and reach the heart.
The heart is then stopped artificially to allow the valve operation to take place and then
restarted afterwards. During the operation a special bypass machine is used to pump blood
around the body. This form of treatment has been performed for many years and is an
excellent way to improve the function of the heart. However, it may not be suitable for all
patients where other medical problems make the operation too risky.
2. Recently a new form of valve replacement has become available. This is called TAVI
(Transcatheter Aortic Valve Implantation). In this procedure, the patient’s own valve is not
removed but is squashed by a tissue valve which is held in place by a metal ring. In TAVI,
the new valve is inserted from the blood vessels in the groin or by a small keyhole cut in the
chest wall. The heart does not need to be stopped for this procedure and a bypass
machine is not routinely used. This may be a lower risk procedure than conventional
surgery for some patients although because it is relatively new, less is known about its
longer term effects.
3. The third option for treatment of aortic stenosis is with medication alone. This is most often
with diuretics (water tablets) or other tablets to help the heart pumping action.
How is TAVI done?
If TAVI is recommended, this may be done via the groin arteries or by a small cut in the left side of
your chest. The decision which is best for you will depend on the results of your tests and the
decision of your cardiologists and surgeons.
The procedure is done under general anaesthetic, so you will be asleep for the operation. Some
special monitoring tubes are placed in the blood vessels in the wrist or neck and a catheter is
placed into your bladder to allow you to pass water freely after the procedure. A tube is placed into
the windpipe and a further tube into the gullet to scan the heart during the procedure.
If the procedure is done via the groin (called a transfemoral approach), a small cut is made to
insert the equipment. This small hole is repaired at the end of the procedure with some stitches.
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If the groin arteries are too small or narrowed, the procedure is done through a small cut in your
chest wall (called a transapical approach) to allow the equipment to get to the heart. After the
valve is inserted, the cut is repaired with some stitches and a small drain is left in place.
In both transfemoral and transapical procedures, your own heart valve is stretched open with a
balloon. After this has been done, the new valve is inserted and expanded by another balloon.
When the balloon is deflated, the new valve is held in place by the surrounding tissues. The new
valve function is then checked by the heart scan before the procedure is completed.
What happens after the procedure?
After the procedure, you will be transferred to the cardiac intensive care unit then moved to the
high dependency unit, coronary care unit or cardiology wards. All of the tubes that had been
inserted during the procedure will be removed to allow you to move around more freely. This may
be done quite quickly afterwards or can take a little more time depending on your rate of recovery.
Whilst in hospital, you will have a series of further tests which may include ECGs, blood tests, xrays or scans. The need for these tests will be decided by your cardiologist or surgeon and will
depend on your overall speed of recovery.
You may be able to be discharged between three and six days after the procedure, although
sometimes this can be longer if your recovery is slower. Occasionally more prolonged stays in the
intensive care unit or other wards are required.
It is usually a good idea to think about what extra help you might need from family or friends once
you are discharged home and to arrange this in advance.
Will I be followed up afterwards?
We will ask you to come back to be seen in clinic after around six to eight weeks to be examined.
We may perform further blood tests, an ECG or echocardiogram at that stage.
If we are happy with your condition, we would then normally arrange to see you in the clinic every
six to 12 months to keep an eye on things. We will usually perform further heart scans during
some of these visits.
Although most patients notice a definite improvement in their quality of life after having a TAVI
procedure, some might have further problems with the heart over time, and this is the reason why
we would like to keep you under review in the clinic.
What are the benefits of the procedure?
A successful procedure relieves the narrowed valve and improves the overall heart function. This
will usually improve symptoms of chest pain, breathlessness and black-outs. This could potentially
improve your overall quality of life and possibly your life expectancy.
What are the risks of the procedure?
As with any operation, there are risks of complications from this procedure. However, there are
also risks from leaving the valve untreated. Your cardiologist / surgeon will weigh up these risks
and benefits carefully with you.
Major risks that can occur either during the procedure or the subsequent few days include:
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





Bleeding or damage to the blood vessels needing further surgery or blood transfusion (6 7%)
Stroke (2-3%)
Heart attack (less than1%)
Death (6-10%)
Emergency open heart surgery (1-4%)
Kidney failure (5-12%)
Serious risks include:





Bleeding into the sack round the heart (<5%)
Permanent pacemaker because of slow heart beat (6-8%)
Reaction to dye (<1%)
Reaction to the anaesthetic (<1%)
Infection (<2%)
Less serious risks include:




Abnormal heart beat
Non emergency further surgery on the valve
Bruising around the wound
Valve leak
Unusually, your medical team may find that it is not possible to insert the new heart valve during
the procedure. This will usually be for technical reasons which do not become obvious until the
procedure begins. In this situation, the doctors treating you may decide to perform a valvuloplasty
alone. This is when the aortic valve is stretched open with a balloon but the new valve is not
inserted.
As all patients will have had detailed investigations before the TAVI procedure, unexpected
findings will be unusual. The chances that the new valve will not be implanted during the
procedure are approximately 1-5%.
Where can I get more information?


The National Institute of Clinical Excellence (NICE) website:
http://www.nice.org.uk/nicemedia/pdf/IPG266PublicInfo.pdf
If you do not have access to the internet, your cardiologist can provide a copy of this
document
Your cardiologist or cardiac
surgeon
Author: R Edwards and D Muir, 1
December 2009
Some sections of the leaflet have been
removed for the purpose of the booklet.
Heart Failure
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Whilst working on coronary care and ward 24 you will be given the opportunity to look at
the treatment and management of heart failure. These patients fall into 2 categories, acute
and chronic heart failure. We have discussed earlier how the heart is a muscular pump, but in
this group of patients this pump isn’t working properly and they can become very unwell
very quickly. Heart failure is just a symptom of their condition; it is also a consequence of
becoming better at keeping people alive with heart disease or disorders.
Definition
By Mayo Clinic staff (http://www.mayoclinic.com/health/heart-failure/DS00061)
“Heart failure, also known as congestive heart failure (CHF), means your heart can't pump
enough blood to meet your body's needs. Over time, conditions such as narrowed arteries in
your heart (coronary artery disease) or high blood pressure gradually leave your heart too
weak or stiff to fill and pump efficiently.
You can't reverse many conditions that lead to heart failure, but heart failure can often be
treated with good results. Medications can improve the signs and symptoms of heart failure
and help you live longer. Lifestyle changes, such as exercising, reducing the salt in your diet,
managing stress, treating depression, and especially losing weight, can improve your quality
of life.
The best way to prevent heart failure is to control risk factors and conditions that cause heart
failure, such as coronary artery disease, high blood pressure, high cholesterol, diabetes or
obesity.”
Niemen, MS in his article Key issues of European Society of Cardiology guidelines on acute
heart failure discusses the finding laid down by the European Society of Cardiology (ESC)
on Acute and Chronic Heart Failure. http://www.escardio.org/guidelines-surveys/escguidelines/GuidelinesDocuments/Guidelines-Acute%20and%20Chronic-HF-FT.pdf. They
examine the definition and severity of acute heart failure and suggest a treatment model.
Classification of AHF
Acute decompensated heart failure, de novo, or decompensation of chronic heart
failure
Hypertensive AHF
Pulmonary oedema, as an AHF accompanied by severe respiratory distress and
usually O2 saturation <90% on room air prior to treatment
Cardiogenic shock: cardiogenic shock is a continuum from low cardiac output
syndrome to cardiogenic shock
High output failure
Right heart failure is characterized by low output syndrome with increased jugular
venous pressure, increased liver size, and hypotension
The patients who are high risk of going into Acute Heart Failure are the patients who are
having an Acute MI. The study showed that about 32% of this patient group would go into
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cardiogenic shock. Not only is the patients breathing affected, but also their blood pressure
will be very low and this will also affect the kidneys. If left untreated this is life threatening.
In the early stages we can manage the patients on CCU, but they often end up on Intensive
Care as they may need multiple types of organ support.
The commonest symptom of the
patients heart failing is pulmonary
oedema ~this is caused by
congestion of the lungs, due to the
inadequate pumping action. The first
thing you will notice changing is the
patient’s respiratory rate closely
followed by their oxygen
saturations. If you are the one with
the patient it is really important that
you report this to the person who is
mentoring you.
The doctor will listen to the patient’s chest and order a chest x-ray – this will clarify whether
the patient is in pulmonary oedema. Depending on the severity he may just treat it with
diuretics i.e. furosemide(I.V). However, if the patient is struggling to breathe they may treat
this more aggressively using other drugs such as GTN (glycerine trinitrate) and
Diamorphine. The aim of these drugs is to help the patient relax and breathe easier and shift
the fluid from the lungs back into the circulation to be excreted by the kidneys. Therefore we
also monitor closely the patient’s fluid intake / output.
Another type of oxygen therapy we use, and have found very successful is CPAP. This is
also known as non-invasive ventilation. It is a form of controlled, pressurised oxygen
therapy. This helps keep the alveoli in your lungs open, whilst absorbing oxygen through the
capillaries surrounding them.
Chronic Heart Failure
The mechanism is the same and these patients can decompensate (deteriorate) and end up
having an acute event. In order to offer best treatment / management it is also important we
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understand the patients underlying condition. We have discussed patients with valve
problems and post infarct earlier, but they are not our only client groups. We also have
patients who have congenital conditions (born with it) and patients who have congenital or
develop a form of cardiomyopathy (feel free to read any of our patients leaflets on this, they
are very informative).
This condition may result in periods of admission, but is also managed very well at home
during the patients’ stable phases. Therefore it is essential that the patient is involved in the
management of their care and has the ability to recognise symptoms of deterioration. The
first visual sign is usually peripheral oedema (swollen ankles) and an increase in their
weight. For this group of patients we advise them to weigh themselves everyday as this
monitor the fluid levels in their system. If they put on more than 2.5kg in weight they need
to discuss this with their GP or Heart Failure Specialist nurse to see if they need their
medication adjusted.
If the congestion is severe, especially in the end stage heart failure group they may also
experience abdominal swelling. This is usually because their liver is congested with fluid.
Their may be an option of transplantation for some and often they will stay with us for
prolonged periods of time, even up until they have their transplant. Other treatment such as
left-ventricular assisted devices may also be an option as a bridge to transplant and you may
be lucky enough to see this.
However, other patients do not fall into this category and for them we will look at symptom
control and eventually palliation if there is nothing further we can do to add to their
treatment. The main focus for palliation is comfort and quality of life. You may have heard
and seen End of Life Pathways in use, in conjunction with this the trust also have palliative
care nurses who can offer support to both the family and the patient. The staff on our ward
are also very good at offering care and support to the family and patients. We also
acknowledge how important it is to support each other too. It is only natural to become
attached to people who you care for over a long period of time and a sad time when they
eventually die.
Modified Early Warning System (MEWS) / Observations
MEWS is now an integral part of our observation charts, but why do we need it?
• The more a patient deteriorates prior to changing management the greater their
chances of dying
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• MEWS is a safety net for our patients to get medical review to them in a timely
manner.
• It does not replace nursing acumen it supports it providing documentation so that
changes with time can be seen. It recommends a minimum base for observation;
patients can clearly be monitored more closely if warranted or concerned.
• MEWS works when the observations are done, documented, scored, review called for
and the review changes management
• Failure of any of these steps places the patients at risk
• Patients from the wards continue to have a documented decline on the wards that
should have prompted an earlier referral to the parent medical team
• Patients are coming to harm / dying as a result
• MEWS must be part of our culture to help protect our patients
This is how the observation chart appears on the front.
A set of observations must have all
6 minimum observations:
Temperature
Heart Rate
Systolic Blood Pressure
Respiratory Rate
Oxygen Saturations
CNS – AVPU score
If urine output is being
MONITORED this must be scored
correctly and the MEWS increased
by 3 if it is less than 30ml/hr
The reverse of this observation chart
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It is possible for the parent medical
team to alter the MEWS scores by
senior medical decision. This
should be done infrequently, only
on senior medical advice,
documented and is to account for
patients where there normal would
score on the standard parameters.
For example a chronic respiratory
patient may have a normal
respiratory rate for them of 24 so
the parent team varies the MEWS
score of 1 in resp rate to start at 25
The audit should account for this –
in practice at present this is rarely
done
If the MEWS is 1 or
more the observations
should be taken at the
recommended
observation frequency
MEWS of 2 or
more requires a
medical review,
this should be
documented in the
notes
Pacemaker
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The opportunity will arise to observe the insertion of a pacemaker and care for the patient
pre and post procedure. Pacemakers are quite common and there are several types
including: Single Lead Pacemakers (VVIR)
 Duel Lead Pacemakers (DDDR)
 Biventricular Pacemakers (commonly used in
heart failure patients – resynchronises heart)
You will hear these names mentioned frequently
and will gain a greater understanding throughout
your placement of when the different types are
used.
Pacemakers are primarily used for patients who have conduction problems causing rhythm
problems or heart blocks (there are several different types of these) this causes the heart rate
to drop and is often only discovered when the patient becomes symptomatic for example
becoming dizzy or suffering blackouts. It is particularly common in the elderly, however low
heart rates can also be caused by some cardiac drugs, but these will be discussed with you.
Some patients cannot tolerate low heart rates (e.g.25-35bpm) and
in such cases a temporary pacing wire may be inserted as an
interim measure until a permanent system can be fitted. The wire is
often inserted via the sub-clavian or femoral vein up into the heart;
it is attached to a small box on which the rate is set. These support
the hearts own pacemaker. We can also use external pacemakers in
an emergency situation to pace the heart; this can be very
uncomfortable for the patients (who may need sedation).
A pacemaker is a small device about the size of a box of matches;
it is commonly inserted into the pocket made in the pectoral area or
behind the pectoral muscle. Once in position it is checked and the
parameters are set, this is done externally and the patient attends
regular out-patient appointments to ensure it is working correctly
and whether the parameters are still ok or need fine – tuning .
On return from the labs we will place the patient back on a telemetry (portable monitoring
system) until their device is checked the following day. We also observe the site to make
sure there is no swelling, which indicates a haematoma is forming under the skin and record
their blood pressure, heart rate and check the rhythm. This needs reporting to senior nursing
/ medical staff and may need a pressure dressing applied or possibly to return to the lab if it
is really bad. We also keep the patient on bed rest and advice them not to do too much or lift
their arm too high incase they dislodge the wire, which also results in a return back to the
lab.
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Patients are also required to have a
chest x-ray to ensure that there are no
complications for example
pneumothorax. The patient will also
need 48 hours of antibiotic cover after
their device is fitted (check the patient
has no allergies to penicillin as
flucloxacillin is commonly used). Most
patients will be able to be discharged
the following day.
Defibrillator
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The Implantable Cardiac Defibrillator (ICD) is a battery – operated device (similar to a
pacemaker) that continuously monitors the hearts rhythm and rate. Its purpose is to detect
any rhythm changes and treat life – threatening arrhythmias by either anti-tachycardia pacing
or defibrillation.
Patients that have had problems with ventricular arrhythmias may have no further problems
once they have been revascularised i.e. with either angioplasty or CABG. Patients known to
have had problems with ventricular arrhythmias pre revascularisation will sometimes have
electrophysiology studies post revascularisation to see if the arrhythmia can be induced. If
arrhythmias are induced the patient may go on to have an ICD inserted.
However, patients that are found to have severely impaired left ventricle (LV) are recognised
to have a high propensity to sudden cardiac death from ventricular arrhythmias,
electrophysiology studies (EPs) and radiofrequency ablation (RFA) may be attempted, but
often an ICD will be inserted.
Other patient groups found to benefit from the insertion of an ICD are those families with
syndromes i.e. congenital long QT syndrome, hypertrophic cardiomyopathy or patients with
heart failure / awaiting transplant.
The insertion of an ICD is very similar to that of a pacemaker however at the end of the
procedure ventricular fibrillation is induced (the patient is sedated for this part) this is done
to ensure that the ICD is working adequately. The post op care and complications of the
procedure are very similar to that of pacemaker insertion.
The patients are closely followed up by the pacing department and if they need further
advice out of hours they can call our unit. However, if they are receiving multiple shocks
with the ICD after they are discharged they will need to be admitted (sometimes via A&E
and sometimes directly to CCU depending on the circumstances) and have their device
interrogated. This can be traumatic for the patient mentally and they often need reassurance
and support.
For the patients who have ICD's inserted because of heart failure they are also offered
cardiac rehab. There is an additional pathway to that of the PCI patients for rehab
specifically for heart failure patients. However, mainstream groups can offer places to
patients with ICD’s who are not symptomatic.
Electrophysiology Studies /
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Radiofrequency Ablation
This is another procedure performed regularly on the ward that you will have the opportunity
to observe and be involved in the care of the patient pre and post procedure.
Electrophysiology Studies (EPs) are
performed on patients who have
problems with palpitations or abnormal
heart rhythms e.g. ventricular tachycardia
(VT), atrial fibrillation (AF) or Atrial
flutter. Again like the angiogram local
anaesthetic is administered, then the
special catheters are inserted into the
femoral vein or artery and passed into
position in the heart. This catheter
incorporates electrodes and when in
position stimulates the heart with
electrical impulses. This aims to find the location in the heart where the abnormal rhythm
(arrhythmia) originates. Once this is located the patient usually goes on to have
radiofrequency ablation.
Radiofrequency Ablation is performed in most cases at the same time as electrophysiology
studies, once the location of the arrhythmia is found. With the use of high frequency waves
the area the arrhythmia originates is ablated. There are often several areas that have to be
tackled but this is dependent on the patients and type of arrhythmia. The procedure can be
very long and complex and can take anywhere between 2-6hours. This procedure is not
without its complications; one of these risks is that areas of the hearts own natural
pacemakers may become damaged in which case the patient would need to undergo
permanent pacemaker insertion.
Common
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Abbreviations Used On Ward 24/24a.
The Heart:LA – Left Atrium
RA – Right Atrium
LV – Left Ventricle
RV – Right Ventricle
AV – Aortic Valve
MV – Mitral Valve
TV – Tricuspid Valve
SA Node – Sino-Atrial Node
AV Node – Atrio-Ventricular Node
SVC – Superior Vena Cava
IVC – Inferior Vena Cava
Procedures:Alcohol Septal Ablation – A.S.A.
Angiography/ Angiogram - Angios/ Caths/ CC or Cor. Angios
Angioplasty - PCI (percutaneous coronary intervention)
AV Node Ablation – AVNA
Cardiac Resynchronisation Therapy – known as bi-ventricular pacing, is used to re-coordinate the action of
the left and right ventricles in heart failure patients.
DC Cardioversion or DCCV– (where a direct current is passed through the heart to aim
to correct an abnormal heart rhythm)
Electrophysiological Studies – EP’s
Implantable Cardiac Defibrillator – ICD
In Stent Restenosis – I.S.R. – narrowing of previously inserted stents
Pacemaker – PPM
 Bi – V (Bi – Ventricular)
 VVI – Single Lead
 DDD - Dual Chamber
Primary PCI – PPCI
Pulmonary Vein Ablation
Radiofrequency Ablation – RFA
Transplant Assessment – Tx. Assess.
Valvuloplasty
Transcatheter Aortic Valve Implantation –TAVI
Following Angiography – Vessels:RCA – Right Coronary Artery
OM – Obtuse Marginal
PDA – Posterior Descending Artery
LMS – Left Main Stem
LCA – Left Coronary Artery – Cx- Circumflex
LAD – Left Anterior Descending Branch
D1 – 1st Diagonal Branch
D2 – 2nd Diagonal Branch
C.T.O. – Chronic Total Occlusion
BMS – Bare Metal Stents
DES – Drug Eluting Stents
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Surgical Procedures:CABG- Coronary Artery Bypass Grafts
AVR – Aortic Valve Replacement
MVR – Mitral Valve Replacement
Acute Coronary Syndrome:NSTEMI – Non ST Elevation Myocardial Infarction
STEMI – ST Elevation Myocardial Infarction
MI – Myocardial Infarction (heart attack)
Ant.MI – Anterior Myocardial Infarction
Inf. MI – Inferior Myocardial Infarction
Lat. MI – Lateral Myocardial Infarction
Post. MI – Posterior Myocardial Infarction
TnT – Troponin T Level
TnI – Troponin I Level
CE / CK’s – Cardiac Enzyme / Creatinine Kinase{These are both blood tests used to determine the extent of
heart muscle damage following a myocardial infarction}.
Thrombolysis:Thrombolysis consists of an IV infusion or bolus injection, used to promote revascularisation and to reduce
mortality – these drugs activate plasminogen to form plasmin, which degrades fibrin and so beaks up
thrombi.
TNK – Tenectoplase
SK – Streptokinase
Reteplase
RTPA / Alteplase – (Recombinant Human Tissue Type Plasminogen Activator)
IV 2b/3a agent:Reopro /Abciximab – this drug inhibits platelet aggregation and thrombus formation, by blocking the
binding of fibrinogen to receptors on platelets. It’s most common use is following the procedure of
angioplasty.
Tirofiban – this drug is used mainly in patients with unstable angina and also in the prevention of early
myocardial infarction.
Cardiac Measurements:CO – Cardiac Output
CVP – Central Venous Pressure
PAWP – Pulmonary Artery Wedge Pressure
Disease Processes:AF – Atrial Fibrillation
A. Flutter – Atrial Flutter
AR – Aortic Regurgitation
AS – Aortic Stenosis
ASD – Atrial Septal Defect
AV Block – Atrio-Ventricular Block
CCF – Congestive Cardiac Failure
CHB – Complete Heart Block
HOCM – Hypertrophic Obstructive Cardiomyopathy
IHD – Ischaemic Heart Disease
LBBB – Left Bundle Branch Block
LVF – Left Ventricular Failure
MI – Myocardial Infarction
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MR – Mitral Regurgitation
MS – Mitral Stenosis
PEA – Pulseless Electrical Activity
RBBB – Right Bundle Branch Block
RHF – Right Heart Failure
SVT – Supra-Ventricular Tachycardia
TR – Tricuspid Regurgitation
VE’s – Ventricular Ectopics
VF – Ventricular Fibrillation
VSD – Ventricular Septal Defect
VT – Ventricular Tachycardia
WPWS – Wolfe-Parkinson White Syndrome
Other Common Conditions:ARF – Acute Renal Failure
COPD– Chronic Obstructive Pulmonary Disease
CRF – Chronic Renal Failure
DU – Duodenal Ulcer
DVT – Deep Vein Thrombosis
ESHF – End Stage Heart Failure
ESRF – End Stage Renal Failure
IDDM – Insulin Dependant Diabetes Mellitus (Type 1)
NIDDM – Non-Insulin Dependant Diabetes Mellitus (Type 2)
PE – Pulmonary Embolus
PVD – Peripheral Vascular Disease
U/A or U/Ang. – Unstable Angina / ACS (acute coronary syndrome)
Common Tests:APTR – Activated Partial Thromboplastin Ratio – used in the controlling of IV Heparin hourly rates and in
blood viscosity for sheath removal.
C. DIF – Clostridium Difficile – stool specimens are sent to the laboratories when
the patient presents with diarrhoea, to rule out the
presence of any bacteria within the specimen.
C+S – Culture & Sensitivity – routine specimens are sent to the laboratories to
determine the presence of any infection.
CSU – Catheter specimen of urine (sterile)
CXR – Chest X-ray
ECG – Electrocardiogram / Electrocardiograph
ECHO
ETT – Exercise Tolerance Test
FBC – Full Blood Count
FBG – Fasting Blood Glucose
GFR – Glomerular Filtration Rate – this is a test used within a transplant assessment to
assess kidney function
MSU – Mid Stream Urine
PFT – Pulmonary Function Tests – (Lung Function)
TOE – Trans-Oesophageal Echo – an echo which is more precise in determining the
presence of vegetations on the valves of the heart or
the overall function of the heart – this is carried out
by the patient being mildly sedated and by the
swallowing of a probe similar to that used in the
procedure of an endoscopy
U&E’s – Urea & Electrolytes
U/S or U/Sound - Ultrasound
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XM or X/Match – Cross match – a blood test used to prepare blood in the transfusion
laboratories for the purpose of blood transfusions or for
use throughout surgical procedures
Administration of Medications:OD – Once A Day
BD – Twice A Day
TDS – Three Times A Day
QDS – Four Times A Day
Mane – In The Morning
Nocte – At Night
Px – As Prescribed
LA – Long Acting
MR- Modified Release
SR – Slow Release
XL – Also a long acting preparation given most often on a daily basis
IC – Intra-cardiac Injection
IM – Intra-muscular Injection
IV – Intra-venous Injection
S/C – Sub-cutaneous Injection
INH – Inhaled – (as in taking an inhaler)
NEB – Nebuliser
PO – Orally
PR – Rectally
SL – Sublingual – (under the tongue)
TOP – Topically – (applied to the skin surface)
E/C – Enteric Coated – ( a special coating preventing the release or absorption of their
contents until they reach the intestine)
IV GTN – Intra-venous Glyceryl Trinitrate – an infusion to control the level of chest pain
IV HEP – Intra-venous Heparin – an infusion also used to treat chest pain by
anticoagulating (thinning) the blood, it is also used
when patients who normally take warfarin have their
warfarin stopped for surgical procedures in order to
maintain their therapeutic range
NSAID’s – Non – Steroidal Anti – Inflammatory Drugs
General Abbreviations:BM – Boeehringer Mannheim Mellitus (blood glucose monitoring)
BO – Bowels Opened
BP – Blood Pressure
CCU – Coronary Care Unit
C.G.S. or C/Shock – Cardiogenic Shock
CPAP – Continuous Positive Airway Pressure
C.P.R. – Cardiopulmonary Resuscitation
D/C – On Discharge
G.K.I. – Glucose Potassium Infusion – (used in the control of diabetes especially in the
case of theatre patients)
HR – Heart Rate
IABP – Intra Aortic Balloon Pump
MRSA – Methicillin Resistant Staphylococcus Aureus
NAD – No Abnormality Detected
NBM – Nil By Mouth
NPU – Not Passed Urine
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O/A – On Admission
ORFT – On Return from Theatre
ORTW – On Return to Ward
P.C.A. – Patient Controlled Analgesia
PU – Passed Urine
RESPS – Respirations
SATS – Saturations (oxygen)
S.O.B. – Shortness of Breath
S.O.B.A.R. – Shortness of Breath at Rest
S.O.B.O.E. – Shortness of Breath on Exertion
TCI – To Come In
TEMP – Temperature
T.P.R. – Temperature, Pulse & Respiration
TPW - Temporary Pacing Wire
TX. - Transplant
Members Of The Multi-Disciplinary Team (M.D.T.):OT – Occupational Therapist – helps in assessing the needs of the patients with regard
to extra services or equipment that may be required in
order for the patient to function more effectively and
safely within their own home environment
Physio – Physiotherapist – helps in the assessing stages of a persons’ mobility and
supplies equipment as he/she feels necessary and liaises
with the OT where necessary if both are involved in a
Patients’ discharge planning
SW – Social Worker – helps in arranging care packages for patients – shopping
housework, meals on wheels etc. they also interact with the OT
and physio where necessary, they will also give advice to families
regarding social security matters
Gayle Grindlay
Sister – Ward 24/24a
Updated September 2009
NHS Foundation Trust
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Student Induction
To be completed within First week of Placement
Orientation to Placement
Signature of
Mentor
Date
Signature of
Mentor
Date
Signature of
Mentor
Date
Signature of
Mentor
Date
Signature of
Mentor
Date
Introduction to Departmental Colleagues and key people
Start finish times etc
Access to changing, toilet, restaurant and library facilities
Break times, dress code etc
Explanation of Telephone facilities
and lines of communication
What to do if sick
Check wearing ID Badge and accessed IT from Trust Induction
Discuss the importance of confidentiality and IT security
Explanation of patient call and emergency buzzer system
Share emergency contact details for student
( this needs to be destroyed at end of placement)
Policies and Procedures
Be made aware of how to access all policies and procedures
Local, Professional and Organisational.
Be aware of how to report accidents / incidents
Care of personal property and Patient property
Be aware of how to contact security and report security incidents
Fire
Ensure have completed annual online update.
Date completed:
Identify location and how to use
extinguishers and alarms on placement
Describe action to be taken on hearing fire alarm.
Meeting point / evacuation process etc
Emergency / Cardiac Arrest Procedure
Identify the location of resuscitation equipment
Describe method of summoning relevant arrest team
Health and Safety
Disposal of waste – Student can identify correct procedure
for disposal of:
Clinical waste
Non Clinical waste
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Infectious waste
Body Fluids
Sharps
Confidential waste
Signature of
Mentor
Date
Signature of
Mentor
Date
Manual Handling –Student should be made aware of equipment
used and its decontamination ( Types can be listed below eg Arjo
hoist )
Electronic Beds
Food Hygiene – Student should be able to demonstrate knowledge
in the safe handling and storage of food and refrigerator care.
Infection Control – Students should be aware of how to access
infection control policies
Hand Hygiene technique Gel, Soap and water
5 Moments of Care
Saving Lives documentation
Bed Cleaning Procedure
Commode Cleaning Procedure
How to use bed pan disposal unit
Placement specific
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