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Ward 23A Neurosciences, Neurology Ward, Student Nurse Induction Programme

WARD 23A

STUDENT NURSE

ORIENTATION PACKAGE

STUDENT NAMEMENTORASSOCIATE MENTOR

Neurosciences Unit, Ninewells Hospital, Dundee, DD1 9SY

Ward 23a Ninewells - Ward Telephone No. 01382 633823

Philosophy/Statement of Values in Relation to the Education of Students

We encourage students to ask questions and will always try to answer them. However, we will expect the students to assist with their own learning by developing a questioning approach. We look forward to hearing their views and suggestions about how we can improve the learning experience for our students.(Evidence of this is by using a student evaluation sheet)


We will : -

Treat students as individuals acknowledging their needs and encouraging their participation in formulating care management plans.

Encourage students to feel part of the care team by involving them in assisting and directing healthcare professionals in providing patient care.

Recognise and value the contribution of all students in the process of planning and carrying out patient care and assist them to achieve/maintain knowledge and skills in order to provide safe and effective care.

(Evidence of this is reflected in the welcome pack and the learning opportunities

Mission statement for the neurosciences department:-

Provide a clean safe and happy caring environment Provide a high standard of care which is

individualised Provide timely communication about care and

treatment Ensure patients have a positive experience Treat patients with dignity and respect Patient centred, consistent, safe, and effective care

for every person every time


Ward 23A believe in a “flexible” approach to visiting

We do not have a strict visiting time policy, however we ask that consideration is given in the morning, at mealtimes, and again at bedtime.

For everyone's comfort we ask that a maximum of 2 visitors per bed is adhered to and visitors may be asked to vacate at times when clinical activity has to take precedence.

We welcome and value visitors to our ward and wholly believe that we should all be seen as partners in the care of our patients.

Welcome to our ward (23A Neurology)Ward 23A is a 16 bedded mixed sex ward which comprises of 14 beds dedicated to Neurology patients and 2 beds dedicated to Neurosurgery patients. Also within our ward we have a Lidocaine infusion suite, which is a 4 chaired suite providing treatment to patients (Monday to Friday) who are under the pain team and the neurology team requiring Lidocaine infusions.

We nurse patients with a variety of neurological and neurosurgical conditions such as Multiple Sclerosis, Epilepsy, Motor Neurone Disease, Parkinson’s disease and spinal surgery etc.


The consultant ward rounds run Monday and Fridays starting at 1045hrs in our ward seminar room. Every Wednesday we also hold a multidisciplinary team meeting (MDT) at 0900hrs in our ward seminar room where we can all collectively discuss and plan the care of our patients.

The nursing staffs on this ward practices a bay nursing approach. Our nurses work a 12 hour shift pattern, however depending on your stage of your training and or preference you will be able to work either 12 hour or 8 hour shifts in negotiation with the University and the Senior Charge Nurse.

The Senior Neurology Ward Team

Nicola Fleming-Stewart

SENIOR CHARGE NURSE

Laura McEwan CHARGE NURSESANDRA LARKIN HEAD OF NURSING – SPECILAIST

SERVICES

WARD ORIENTATION

ACTIVITY DATE & SIGN

Introduction to your mentor(s)Introduction to the Senior Charge Nurse


Location of emergency equipment

If asked to telephone for help, Dial 22 22 and state for example “cardiac arrest ward 23A, bay/bed”Location of Fire exits, procedures and equipmentInfection Control matters (linen, PPE for example)Health and Safety matters (equipment, checks etc.)Uniform policyOff duty and reporting absences procedures, explanation of ward routine, Meet the MDTSpend some time with the neurology specialist nursesBe made aware of policies and documentation relevant to this clinical areaAgree to our mission statement and way of working

1 st Year Student Nursing Objectives – for Neurology Ward 23A

Objective Discussed

Demonstrated

Achieved

1. Observe and participate in patient personal hygiene needs.2. Observe and participate in urinary catheter care. 3. Observe and participate in recording vital signs (SEWS, GCS, Blood glucose monitoring).4. Observe and participate in the in pressure area care. PUP policy.5. Observe and participate in admission and discharge procedures.6. Observe and participate in the care and monitoring of patients nutritional needs, MUST policy, including Peg, NG etc. 7. Observe and participate in fluid balance8. Observe and participate in ongoing nursing documentation and assessment.9. Be able to understand and practice good infection control, (PPE, Hand hygiene etc).10. Observe and participate in MDT working.11. Observe and participate in the care of patients in the Lidocaine suite.12. Meet specialist neurology nursing team.13. Care rounds and other specific neurology recording sheets and practices.14.


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2 nd & 3 rd Student Nursing Objectives – for Neurology Ward 23A

Objective Discussed

Demonstrated

Achieved

ADMISSION & DISCHARGEAdmission/Discharge ProcedureTransfer of patient to another wardCare of patient valuable/propertyReceiving phone messagesLast offices

OBSERVATIONS/CHARTSSEWS Neuro obs (+ GCS)Fluid and food chartSeizure chartCare roundingCARE OF PATIENTS PRE AND POST OP

* Preparing a patient for theatre* Post op care of a patient following theatre* Care of a patient receiving an LP* Care of patient receiving Igg

WARD MANAGEMENT/MISCELLANEOUS


General ward managementOrdering drugs, ambulancesPartake in supervised medication roundsAttend MDT meetings, ward roundsUnder supervision take charge of workload

SOME COMMON TERMS USED IN NEUROSCIENCESADENOMA Benign tumourANEURYSM Abnormal dilation of an arteryANGIOMA Congenital swollen collection of blood vesselsAPHASIA Loss of the ability of speakAPRAXIA Loss of skilled movements despite

preservation of power, sensation and coordination

ATAXIA Loss of the ability to coordinate voluntary movements

BULBAR PALSY Weakness of the tongue, pharynx and larynx due to disease of the lower cranial nerves

CEPHALIC Relating to the headCSF Cerebro-spinal fluidCRAINOTOMY Neurosurgical procedure to the cranial cavityDISCECTOMY Surgical removal of a discDYSRTHRIA Inability to pronounceDYSPHAGIA Inability to swallowHEMIPARESIS Weakness of one side of the bodyHYDROCEPHALUS An excess of CSF inside the skull due to an

obstruction in normal CSF circulationLAMINECTOMY Removal of the vertebral laminaLOBECTOMY Surgical resection of a lobe of the brainMENINGITIS Inflammation of the meningesMENINGES The surrounding membranes of the brain and


spinal cordMENINGIOMA Slow growing tumour arising in the meningesNEUROMA Tumour derived from nerve cellsNYSTAGMUS To and fro movement of the eyesPAPILLODEMA Swelling of the optic nervesPHOTOPHOBIA Intolerance of lightPOSTERIOR FOSSA Back of the skullPTOSIS Abnormal dropping of the eyelidQUADRIPLEGIA Paralysis affecting all four limbsRHINORRHEOA-CSF Leak from the noseSEIZURE Sudden disturbance of consciousness or

sensorimotor functionSPONDYLOSIS Degeneration of the spineSUBARACHNOID SPACE

Between the arachnoids and pia mater layers, contains CSF

SUBDURAL Beneath the dura mater

This list is by no means extensive.

Revision of the Anatomy and Physiology of the Nervous System

The Skull

The skull is a bony structure and is made up of two parts, the cranium and the face.The cranium consists of eight bones:One frontal bone (This is the bone of the forehead)Two parietal bones (These bones form the sides and the top of the skull)Two temporal bones (These bones lie on either side of the head and are divided into four parts)One occipital bone (This bone forms the back of the head and part of the base of the skull)One sphenoid bone (This bone forms the middle portion of the base of the skull)One ethmoid bone (This bone forms the anterior part of the base of the skull and helps to form the orbital cavity, the nasal septum and the lateral walls of the nasal cavity)

The Brain

The brain makes up about one fiftieth of the body weight and lies within the cranial cavity. The structures that form the brain are:The cerebrum of fore brain-This is made up of the cerebral hemispheres, the thalamus and the basal ganglia.


The brain stem-This is made up of the midbrain, the pons varolli and the medulla oblongata.

The Meninges

The brain and the spinal cord are completely surrounded by three membranes known as the meninges. Starting with the outer these are:The dura mater-A double layer that lines the inside of the skull. The outer layer is the periosteum of the bone. The inner layer extends throughout the skull creating compartments. There are four folds of dura in the skull cavity, which support and protect the brain. The spinal dura is a continuation of the inner layer. The outer layer stops at the foramen magnum.The arachnoid mater-Thin and delicate, it loosely encloses the brain. The spinal arachnoid is a continuation of the cerebral arachnoid. As it contains blood vessels it can be damaged by lumbar or cisternal puncture which can result in haemorrhage.The pia mater-Mesh like and vascular, it covers the surface of the brain. It dips down between the convolutions of the brain surface. When it reaches the spinal cord it is thicker, firmer and less vascular.

The Spine

The spine is made up of 32-34 vertebrae, which are grouped in 5 regions: 7 Cervical-The cervical vertebrae are smaller than those in the

other areas of the spine. The first vertebra is known as the atlas. The second vertebra is known as the axis. Each of these are


unique in shape. The axis has a projection called the odontoid peg upon which the atlas sits. This allows for the rotational movement of the head.

12 Thoracic-The thoracic vertebrae are intermediate in size, but become larger as they reach the lumbar vertebrae.

5 Lumbar-The lumbar vertebrae are the largest. 5 Sacral-The vertebrae now start to decrease in size as weight is

transferred to the hip bones and the legs. 3-5 fused-Which is known as the coccyx

Along with the intervertebral discs the vertebrae form a jointed column. When viewed from the side it has curvatures, concave posteriorly in the cervical and lumbar regions, and concave anteriorly in the thoracic and sacral regions. When a child is born the spine has a single primary curve, concave anteriorly. The secondary curves in the cervical and the lumbar regions appear in the first two years of a child’s life as they learn to hold their head up and learn to walk. Movement of the spineMovement between the individual vertebrae is restricted in order to protect the spinal cord. Movement of the spine as a whole consists of a) Flexion b)Extension c)Lateral flexion d)Rotation. There is more movement in the cervical and the lumbar regions than anywhere else.


ROUTINE INVESTIGATIONS


CT Scan

CT Scan stands for computerised axial tomography scan. Beams of x-ray slice through the patient’s body and are read by a detector on the opposite side. The scan shows varying densities of tissue. It is useful for identifying cranial lesions such as abscesses, cysts, haematomas, hydrocephalus and primary and metastatic tumours.

MRI Scan

Similar to a CT scan but no radiation is used. The images are extremely clear and detailed. It provides anatomical information about the chemistry and physiology of living tissue. Particularly effective in detecting necrotic tissue, oxygen deprived tissue, small malignant tumours and degenerative disease within the central nervous system. When lying on the MRI table the patient is in a strong magnetic field. Any patients with invasive metallic objects, i.e. aneurysm clips or pacemakers cannot be exposed to MRI.

Angiography

The cerebral vessels are visualised by the injection of radio-opaque contrast medium and then a series of x-rays are taken. It is performed to demonstrate abnormalities in the cerebral blood flow and also to demonstrate how vascular defects are in relation to the position of the cerebral arteries, i.e. cerebral aneurysms, arteriovenous malformations (AVM).

Lumbar Puncture

A spinal needle is inserted into the space between lumbar vertebrae 3 and 4 or 4 and 5 to obtain a specimen of cerebrospinal fluid, (CSF) for analysis. It may also be carried out to measure the pressure of CSF, to introduce drugs or for spinal anaesthesia during surgery.

TYPES OF CEREBRAL TUMOUR

Tumours involving cerebral hemispheres are likely to present with epilepsy and progressive motor and sensory deficits on the opposite side. Frontal or temporal tumours may produce psychiatric


symptoms and may reach a large size before being recognised. Progressive visual problems may be due to compression of the visual pathways by i.e. meningioma or craniopharingioma. Posterior fossa tumours present with headaches, papilloedema and possibly poor balance and co-ordination.

GliomasThe most common primary intracranial tumour and the range of malignancy is wide. Radical excision is practically impossible, as there is no clear edge to the tumour.

GlioblastomasRapid growing, not controlled by therapy, prognosis poor.

AstrocytomasShow a wide variation in malignancy. Some evolve slowly over many years. Surgical treatment is of limited value and there is no effective therapy.

MeningeomasThese are benign and from 15% of all intracranial tumours. If the meningioma is removed completely the outlook is good. Even when the tumour is not completely removed growth may continue very slowly. There is recurrence.

Accoustic NeuromasSymptoms: tinnitis, deafness and vertigo. Deafness and vestibular loss on the affected side are often present before surgery and persist afterwards. Facial palsy can also be present. Some surgeons advise partial excision. The outlook is much better when the tumour is small.

Pituitary TumourSymptoms: Visual problems, headaches, paresis of extraocular muscles, endocrine disorders (e.g. acromegaly, and gigantism)Surgical removal is usually carried out via a transnasal route and then followed by radiotherapy. Prognosis is very good to excellent.


HEAD INJURY

Approximately one million people in the United Kingdom attend hospital each year following a head injury. Of these 1000,000 are admitted to hospital and 10,000 are transferred to a neurosurgical unit. (Gentleman and Patey, 1998)

Head injury is more common in males than females. The commonest age group is 15-29 and then over 65 years of age. Some of the common causes of head injury seen in ward 23b are: Road Traffic Accidents, Falls, Assaults, Sports Injuries and Industrial Accidents.

Types of Injury

Diffuse Injury Concussion: The word concussion means to shake violently. A

cerebral concussion is defined as a transient, temporary neurogenic dysfunction caused by mechanical force to the brain.

Diffuse axonal injury: Is a primary injury of diffuse microscopic damage to axons in the cerebral hemispheres, corpus callosum and brain stem. (Hickey, 1997)

Focal Injuries Cerebral Contusion: Bruising of the surface of the brain Cerebral Laceration: Traumatic tearing of the cortical surface

of the brain Intracranial Haemorrhage: A common complication of head

injury. Can occur beneath a fracture or from an acceleration-deceleration injury. (Hickey, 1997)

Penetrating InjuriesThese can be described as: Tangential injuries where the cranial cavity is not entered but

the result of the injury is a depressed skull fracture, scalp laceration, and meningeal and cerebral contusion-laceration.

Penetrating injuries where the cranial cavity is entered resulting in bone fragments, hair etc within the brain. (Hickey, 1997)

Damage to the skullIf the skull is fractured the bone will heal itself. The reason that patients are admitted to hospital is as a precaution to prevent further injuries such as infection. If the fracture is depressed with fragments projecting inwards then there is an increased risk of infection and epilepsy.

Assessment of conscious level


The Glasgow Coma Scale (GCS) WAS DEVELOPED IN Glasgow in 1974 and is now used all over the world to standardise observations for the objective and accurate assessment of level of consciousness. The GCS is especially useful to monitor changes in unstable comatose patients and during the first few days after an injury. In ward 23b all patients sustaining and trauma/surgery to their head will be assessed using the Glasgow Coma Scale.

Head injury is a vast subject and this is a very brief overview. Therefore I have suggested further reading material below.

Suggested further readingHickey, J.V., (1997). “The clinical practice of Neurological and Neurosurgical Nursing”. 4th Edition. Lippincott, Philadelphia.

References

Gentleman, D. and Patey, R. (1998). Trauma Care: Beyond the resuscitation room. Chapter six. Head Injury. Driscoll, P and Skinner D. (Eds). BMJ Publishing Group.

Hickey, J.V. (1997). The clinical practice of neurological and neurosurgical nursing. 4th Edition. Lippincott, Philadelphia.

Evaluation


Here on ward 23A we appreciate your views, please can you complete this short evaluation and return to the senior charge nurse on your last day of placement. Thank you in advance for your time.

Name (optional) ___________________________________________________

Date__________________________________

1. Did you find the placement learning outcomes appropriate to your level of skill and knowledge?

Very Quite Not at all

2. Did you find the staff welcoming and helpful?


3. Did you have an appropriate induction and introduction to placement and staff?


4. Did you find the induction pack helpful?


5. Is there any subject you would have liked to have covered that was not covered?

Yes No Specify:

6. Was there adequate time allotted to you for discussion of your learning plan, progress and assessment?

Yes No

7. Do you have any suggestions on ways to improve the placement for students?

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