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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 INTERPERSONAL SKILLS CLINICAL SKILLS PATHOPHYSIOLOGICAL PROCESS HEALTH DEVELOPMENT OPPORTUNITIES MANAGEMENT OF CARE ORGANISATIONAL AND MANAGERIAL ISSUES THE HEART 11 ANATOMY AND PHYSIOLOGY THE CONDUCTION SYSTEM THE ECG HEART RATE “READY RECKONER” ISCHAEMIC HEART DISEASE 15 ANGIOGRAPHY ANGIOPLASTY (UNSTABLE / PPCI) CABG SECONDARY PREVENTION (MEDICATION / REHAB) AORTIC STENOSIS 21 TAVI AORTIC VALVE REPLACEMENT HEART FAILURE 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 2 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 Added to Practice Placements, Northumbria University Website July 2012 3 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 4 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 Added to Practice Placements, Northumbria University Website July 2012 5 LEARNING OPPORTUNITIES USE OF THE TELEPHONE MAKING / ANSWERING CALLS RING BACK TRANSFERRING CALLS TEAM MEMBER WHO CAN PROVIDE LEARNING OPPORTUNITIES WARD CLERK NURSES USE OF THE COMPUTER 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 6 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 7 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 Added to Practice Placements, Northumbria University Website July 2012 8 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 9 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 10 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 11 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 Added to Practice Placements, Northumbria University Website July 2012 12 DON’T FORGET TO LOOK AT YOUR PATIENT Added to Practice Placements, Northumbria University Website July 2012 13 Ischaemic Heart Disease Added to Practice Placements, Northumbria University Website July 2012 14 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 Added to Practice Placements, Northumbria University Website July 2012 15 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) Added to Practice Placements, Northumbria University Website July 2012 16 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 Added to Practice Placements, Northumbria University Website July 2012 17 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. Added to Practice Placements, Northumbria University Website July 2012 18 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 Added to Practice Placements, Northumbria University Website July 2012 19 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 Added to Practice Placements, Northumbria University Website July 2012 20 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. Added to Practice Placements, Northumbria University Website July 2012 21 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 Added to Practice Placements, Northumbria University Website July 2012 22 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. Added to Practice Placements, Northumbria University Website July 2012 23 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: Added to Practice Placements, Northumbria University Website July 2012 24 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 Added to Practice Placements, Northumbria University Website July 2012 25 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 Added to Practice Placements, Northumbria University Website July 2012 26 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 Added to Practice Placements, Northumbria University Website July 2012 27 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 Added to Practice Placements, Northumbria University Website July 2012 28 • 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 Added to Practice Placements, Northumbria University Website July 2012 29 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 Added to Practice Placements, Northumbria University Website July 2012 30 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. Added to Practice Placements, Northumbria University Website July 2012 31 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 Added to Practice Placements, Northumbria University Website July 2012 32 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 / Added to Practice Placements, Northumbria University Website July 2012 33 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 Added to Practice Placements, Northumbria University Website July 2012 34 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 Added to Practice Placements, Northumbria University Website July 2012 35 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 Added to Practice Placements, Northumbria University Website July 2012 36 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 Added to Practice Placements, Northumbria University Website July 2012 37 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 Added to Practice Placements, Northumbria University Website July 2012 38 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 Added to Practice Placements, Northumbria University Website July 2012 39 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 Added to Practice Placements, Northumbria University Website July 2012 40 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 Added to Practice Placements, Northumbria University Website July 2012 41