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  • 1. B26 STUDENT INFORMATION AND LEARING OPPORTUNITIES PACK Your mentor is ……………………………… Your Associate mentor is……………………………
  • 2. THE RENAL WARD B26 Welcome to the Renal ward B26 we are an inpatient area for people with long-term renal problems and acute episodes of renal failure. It is a 23-bed ward with an acute dialysis bay. The ward is divided into two teams. We use the Named Nurse and Team Nursing concepts together Patients are admitted to the ward for various reasons; those with long- term renal problems include admission for dialysis access or current access problems and infection. Patients are admitted for renal investigations and biopsies, via Gp, s when blood results come back abnormal. Patients admitted with acute renal failure are often severely unwell therefore require urgent specialist care. On the ward we provide a wide variety of care and treatments. We hope you find your time with us productive and enjoyable, allowing you to gain inside knowledge into how people are looked after within our department
  • 3. Who’s Who? WARD SISTER JUNIOR SISTER MATRON Navy Uniform. Navy Uniform White Uniform Red trim Navy trousers STAFF NURSES PDN AUXILLARY NURSES RENAL SUPPORT NURSES Pale Blue Uniform. White Uniform Beige Uniform. White Tunic. With navy trim White Tunic. (With Pale Blue Epaulettes) Navy trousers (With Beige Epaulettes) STUDENT NURSES. SPRINGBOARD. White Tunic. Pale Green Uniform Black Trousers. DOMESTIC STAFF. PHYSIOTHERAPISTS. Yellow Tunic/Dress. Navy Trousers. Navy Trousers/ Top White Tunic. OCCUPATIONAL RADIOGRAPHERS WARD CLERKS THERAPISTS. Green Trousers Burgundy Trousers White Tunic White Tunics. White Tunics. Black trousers
  • 4. RENAL AMBULATORY CARE DEPARTMENT The Team consists of 4 staff • Department Manager/Anaemia Specialist Nurse • CAPD Nurse • Transplant / Pre D nurse • HCA This is a very busy Nurse led department covering various requirements and aspects of patient care. These include; • Training patients for dialysis • Reviewing home dialysis patients • Educating patients • Preparing patients for dialysis and transplant • Clinics • Reviews from discharges and Clinics • Planned treatments/day cases • Theatre The CAPD Nurse is a primary nurse for her caseload of patients. Her work involves training the patients to do home dialysis in various forms. This training and follow up care maybe carried out in the home, which allows a patient, centred approach to their care. The CAPD Nurse is also involved in the preparation, insertion and after care of the patient and their access. To ensure we are offering the best standard of care. The Nurse is involved in the monitoring and reviewing of standards and protocols. The Transplant and Pre Dialysis Nurse is also the primary nurse for her caseload of patients. This role is primarily educational and offering information so as the patient can make an informed choice about their treatment and options. Communication skills are essential and the ability to deliver the information at a level and with a content that is appropriate for the patient. The Nurse is also involved in the organisation of investigations and tests required for transplant work up and dialysis. This
  • 5. May involve liaison and referral with members of the multidisciplinary team in and out of the renal department. The Role of the Renal Anaemia Nurse specialist is to work within the renal team and enhance the treatment of anaemia to achieve the British Renal standards. This requires a motivated and enthusiastic facilitator. The Nurse works under their own initiative and is able to plan their own workload. They must also have knowledge and ability to make decisions about treatment and any changes required in accordance with patient group directives. The role of the anaemia nurse is very much educational not only towards the patients and relatives but to fellow colleagues and staff. This maybe within the renal department, other areas or the community. The ability to disseminate information using various effective communication skills and recourses enables a safe and efficient practice. ROLE OF THE ANAEMIA NURSE • Nurse led clinics working within guidelines • Intravenous iron clinics • Acts on referrals from nephrologists • Co-ordinated the prescriptions and supply of erythropoietin • Educates patients/relatives/staff/GP/ community nurses • Forwards regular audits • Liaises with company suppliers of Erythropoietin • Organises educational sessions and updates • Monitors patients practice and wellbeing The Health care assistant works with both members of the department, she has gained extended skills and knowledge from working in the department. These skills include theatre work, clinics and venepuncture
  • 6. LEARNING OPPORTUNITIES ORGANSATIONAL AND MANAGERIAL ISSUE LEARNING RESOURCE/RELEVANT/PERSONNEL/DEPT OPPORTUNTIES Managing a team: Organisational skills Delegation skills Registered nurse/team leaders/manager Prioritising skills Registered nurse/team leaders/manager Time management Registered nurse/team leaders/manager Leadership Registered nurse/team leaders/manager Off duty Registered nurse/team leaders/manager Managing patient Team leaders/manager workload Registered nurse/team leaders/manager Quality Registered nurse/team leaders/manager Standards of care Registered nurse/team leaders/manager Implementing change Giving information to: Registered nurse/team leaders/manager Staff Registered nurse/team leaders/manager Doctors Registered nurse/team leaders/manager Patients Registered nurse/team leader/manager Relatives Registered nurse/team leaders/manager Multi-disciplinary team Registered nurse/team leaders/manager members Other departments Registered nurse/team leaders/manager Resources: Registered nurse/pharmacist stores Stock control Registered nurse/pharmacist Drugs Registered nurse/TSSU TSSU Registered nurse/stores Materials management Registered nurse/stores Non-stock Registered nurse/ward clerk Stationary Ward manager Establishment/skill mix Budget control
  • 7. Ward manager Managing risk: Registered nurse Policies and procedures Health and safety officer/electronics Equipment safety checks Health and safety officer and link nurse Quality control Domestic supervisor Environment checks Control of infection sister Infection control Moving and handling co-ordinator Moving and handling Link nurse COSHH Link nurse Health and safety Registered nurse/arrest team Emergency situations Registered nurse/security officer Cardiac arrest Registered nurse/fire officer Violent incidents Registered nurse/health and safety officer Fire Registered nurse/bed manager Patient falls Bed alerts Registered nurse/HCA Staff development Registered nurse/HCA Clinical supervision Reflective practice
  • 8. LEARNING OPPORTUNITIES PATHOPHYSIOLOGICAL PROCESS LEARNING OPPORTUNITIES RESOURCES/RELEVANT/PERSONNEL/ DEPARTMENT Infection: Inflammatory process Registered nurse/Doctor/Pharmacist Source Book/Articles Natural spread Treatment Immunological factors: Antigens Registered nurse/Doctor/Pharmacist Autoantigens Books/Articles Suppression of the immune system Drugs Disorders Disturbances in electrolytes and water balance: Anatomy and physiology Registered nurse/Doctor/Pharmacist/Renal Normal electrolyte balance team/Dietitian Reading and understanding blood Books/Articles results Dehydration Fluid overload Acidosis Investigations Oncology: Aetiology Registered nurse/Pharmacist/Macmillan Epidemiology nurse/Hospice/Chemotherapy Pathology unit/Radiotherapy department Treatments Books/Articles Chemotherapy/Radiotherapy/Drug s
  • 9. Cardiovascular system: Registered Nurse/Thrombolysis Anatomy and physiology nurse/Doctor/ECG department/Angiograph ECG nurse/Heart failure nurse/ Investigations Books/Articles Treatments Myocardial infarction Angina Heart failure, CCF, LVF Cardiac Arrest Hypertension Cardiac Arrhythmias Drugs Respiratory system: Anatomy and physiology Registered nurse/Respiratory nurse/Doctor/ Investigations Pulmonary technician/physio therapist Infection Books/Articles Treatments Chest infection COPD Asthma Emphysema Drugs, nebulizers, inhalers, oxygen therapy Kidney and genitourinary system: Registered nurse/ Doctor/ Renal nurse/ Anatomy and physiology incontinence Infections nurse/Radiology/Pharmacist/Renal Drugs department/ Dietitian Investigations Books/Articles Testing urine Pyelonephritis Fluid Balance Glomerulnephritis Polycystic kidney disease Auto immune disease Diabetic nephropathy Renal vascular disease Nephrotic syndrome Kidney stones/Obstructive nephropathy Acute renal failure Disease of the Blood: Doctor/Registered nurses/ Anaemia nurse Blood formation and destruction specialist/Haematology unit/Pathology lab process Books/Articles Red blood cells
  • 10. LEARNING OPPORTUNITIES INTERPERSONAL SKILLS Learning Opportunities Resources/Relevant personnel/department Use of telephone; Answering calls Ward clerk/ward staff Making calls Ring back Ward clerk/ward staff Bleep system Ward manager/clinical lead Use of computer to obtain; Patient investigations Registered /Auxiliary nurse Patient information Talking to; Patients Doctors/Multi-disciplinary team Relatives Registered nurses/OT/Physio/Social Doctors worker/Specialist nurses Other nurses including specialist Domestics nurses Registered nurses Multi-disciplinary team referrals Doctors/Registered Ancillary staff nurses/Pharmacists MDT meetings Ward clerks/Ambulance Doctors ward rounds control/hospital Consultant ward rounds Transport Dept Booking transport Registered nurses/doctors/ward clerk Facilitating investigations Registered nurses Nurses handovers Ward manager Managerial structure in Trust Observation of role Team working Patient/relative/registered nurse/bed Patient transfer within Trust Manager/porter/ambulance crew Patient transfer outside the Trust
  • 11. LEARNING OPPORTUNITIES. MANAGEMENT OF CARE Learning Opportunities Resources/Relevant Personnel/Department Use of nursing model Registered nurse Philosophy of care Registered nurse Documentation used Registered nurse Nursing Process; Assessment How is assessment carried Registered nurses out/open or closed questions? Sources of information What is assessed? Patient/relatives/doctor/pharmacist/notes/district Where does it take place? nurses/specialist nurses. Planning Care plans Registered nurses Risk assessment tools Registered nurse/Link nurses Care pathways Registered nurse/specialist nurse Multi-disciplinary plan/working MDT Discharge plan Discharge liaison nurse Referral to other agencies; OT Registered nurse Physio Registered nurse/Doctor Social worker Registered nurse District nurse Registered nurse Discharge liaison Registered nurse Specialist nurse Registered nurse Critical care outreach nurse Registered nurse Macmillan nurse Registered nurse Implementation/Evaluation Ward rounds MDT Registered nurse/Doctor Documentation Registered nurse/General office Standards Registered nurse/Doctor Protocols/Policies Registered nurse/hospital Chaplin/priest
  • 12. Communication/patients/relatives Time management Planning priorities Dealing with difficult situations Deceased patients Patient property/Valuables Self discharge Religious needs/arranging priests
  • 13. LEARNING OPPORTIUNITIES CLINICAL SKILLS LEARNING RESOURCE/ OPPORTUNITIES RELEVANT/PERSONNEL/DEPARTMENT CORE SKILLS: Registered/HCA/occupational therapist Patient hygiene Registered/HCA Mouth care Registered/HCA/Doctor Hair/nail care Registered nurse/Diabetic nurse specialist Skin care Registered /HCA Pressure care prevention [Braden Scale] Registered nurse Recording of physiological observations: Blood Pressure Temp, Pulse, Resps Weight Blood Glucose Urine Output Maintaining accurate charts Registered nurse Pharmacist/Doctor Giving medications: Registered nurse Oral Intravenous Intramuscular Subcutaneous Registered nurse/Medical electronics Rectal Intravenous infusions Cannulation/care of venflons Medical devices Registered nurse/HCA Infusion pumps Syringe drivers Phlebotomy/venepuncture Administration of blood/blood products Registered nurse/Dietitian Aseptic techniques i.e.
  • 14. dressings Risk assessment Nutritional intake Registered nurse/physiotherapist/moving and BMI handling advisor Falls assessment Moving and handling Use of aids Registered nurse/Infection control nurse Hoists Registered nurse/ HCA I Registered nurse Infection control Isolation of patients Registered nurse/physiotherapist/moving and Catheter insertion and care handling advisor Test urine Registered nurse/HCA Central venous pressure Registered nurse/Doctor lines Registered nurse Patient safety Registered nurse/radiology nurse/Doctor Checking equipment Registered nurse/radiology nurse/Doctor Preparation for investigations: Consent Registered nurse Information Registered nurse Invasive radiology Registered nurse Non-invasive radiology Auxiliary /registered nurse Registered nurse/Doctor/Secretaries/ward clerk SPECIALIST SKILLS Registered nurse/doctor/ HCA Anaemia nurse Registered nurse Erythropoeitin s/c Registered nurse/Doctor/HCA/Technician Storage of EPO Registered nurse/DA Iron infusions Registered nurse/patient/carer Monitor bloods Registered nurse/doctor/consultant Follow up Registered nurse/HCA/doctor appointments/clinics Venepuncture Cannulation E.C.G Haemodialysis C.AP, D/APD Clinics/Pre- d/transplantation/Review Ambulatory care Department
  • 15. WHERE ARE THE KIDNEYS The kidneys are two bean-shaped organs about the same size as a fist. They are located near the middle of the back, one on either side of the spine.
  • 16. system filters waste products out of the blood and makes urine. It is made up of the • Kidneys • Ureters • Bladder • Prostate (in men) • Urethra Kidneys, waste products and unneeded water are collected and turned into urine The urine is gathered in an area called the renal pelvis at the centre of each kidney. From there it drains into the bladder down a tube called the urethra. There are two ureters – one from each kidney. Another tube called the urethra carries urine from the bladder out of the body. Inside the kidney, the blood is filtered through very small networks of tubes called nephrons. Each kidney has about 1 million nephrons. Inside the nephrons, waste products in the blood move across from the bloodstream (the capillaries) into the urine-carrying tubes inside the nephron. These tubes are called tubules. As the blood passes through the vessels of the nephron, all unwanted waste is taken away. Any chemicals needed by the body are kept and returned to the bloodstream by the nephrons. In this way, the kidneys help to regulate the levels of chemicals in the blood such as sodium and potassium. So the right levels are maintained to keep the body healthy. WHAT THE KIDNEYS DO? • Fluid Balance • Electrolyte Balance – K, CA,P, NA, CL • Acid Base Balance • Hormonal – RAAS, Erythropoitein, Vitamin K • Removal of waste Creatinine and Urea • Removal of some Drugs and Toxins
  • 17. WHAT FUNCTIONS CAN DIALYSIS REPLACE • Fluid Balance • Electrolyte Balance • Some Drug Removal • Acid Base Correction • Removal of Metabolic Waste PHYSIOLOGICAL PRINCIPALS OF RENAL REPLACEMENT THERAPY: Osmosis: The movement of water across a semi -permeable membrane to achieve equilibrium. Dissolved particles cannot pass the membrane nevertheless the concentrations tend to equal out, thus waters moves from the high concentration to a low concentration across the membrane. Diffusion; The random movement of solutes from higher concentration to a lower concentration dependant on the concentration gradient, molecular weight, membrane resistance. Ultra filtration: The movement of fluids through a semi permeable membrane due to a pressure gradient. Ultra filtration is erected by the amount of pressure applied (TMP) and the permeability of the membrane to water (KUF) Convection: The movement of water by hydrostatic forces, therefore solutes are removed by solvent drag that is they are carried along with the passage of water through the pores Principles behind HD: Diffusion, Ultra filtration Principles behind HF: Ultra filtration, Convection Principles behind HDF: Diffusion, Ultra filtration, Convection
  • 18. HEAMODIALYSIS ACCESS There are three forms of vascular access • Permanent Line • Temporary Line - Internal/ external jugular Femoral Subclavian dialysis catheter is a catheter used for exchanging blood to and from the hemodialysis machine from the patient. The dialysis catheter contains two lumens: • Venous • Arterial This is a confusing terminology for layperson, because both lumens are in the vein. The arterial lumen (typically red) withdraws blood from the patient and carries it to dialysis machine, while the venous lumen (typically blue) returns blood to the patient (from the dialysis machine). Flow rates of dialysis catheters range between 200 to 500 ml/min.
  • 19. • Graft and Fistula – permanent internal For both fistulas and grafts, the connection between your artery and vein increases blood flow through the vein. In response, your vein stretches and becomes strengthened. This allows an even greater amount of blood to pass through the vein and allows your dialysis to proceed efficiently.
  • 20. The Heart The heart is a dual pump, circulating blood through two separate closed systems. Oxygen-carrying blood leaves the left ventricle through the aorta. It circulates through the body and returns, deoxygenated, to the right auricle via the superior and inferior vena cava. The right ventricle pumps this blood through the pulmonary artery to the lungs, where it exchanges carbon dioxide for oxygen. Oxygenated blood then returns to the left auricle of the heart, ready for arterial circulation, through the pulmonary veins.
  • 21. Circulatory System The circulatory system functions in the delivery of oxygen, nutrient molecules, and hormones and the removal of carbon dioxide, ammonia and other metabolic wastes. Capillaries are the points of exchange between the blood and surrounding tissues. Materials cross in and out of the capillaries by passing through or between the cells that line the capillary,
  • 22. HUMAN LUNGS Though the right lung has three lobes, the left lung, with a cleft to accommodate the heart, has only two. The two branches of the trachea, called bronchi, subdivide within the lobes into smaller and smaller air vessels. They terminate in alveoli, tiny air sacs surrounded by capillaries. When the alveoli inflate with inhaled air, oxygen diffuses into the blood in the capillaries to be pumped by the heart to the tissues of the body, and carbon dioxide diffuses out of the blood into the lungs, where it is exhaled.
  • 23. The Nervous System The Nervous System is the most complex and delicate of all the body systems. At the centre of the nervous system is the brain. The brain sends and receives messages through a network of nerves. The spinal cord is a thick bundle of nerves, which runs down the centre of the spine. This is like a freeway. Along the spinal cord smaller bunches of nerves branch out. From these bundles, smaller bundles of nerves branch out again. Finally individual nerves branch out to every part of the body. This network allows the brain to communicate with every part of the body. Nerves transmit information as electrical impulses from one area of the body to another.
  • 24. The Endocrine System The endocrine system is a control system of ductless glands that secrete hormones that circulate within the body via the bloodstream to affect cells within specific organs. It is also instrumental in regulating mood, growth and development, tissue function, and metabolism, as well as sexual function and reproductive processes. (1) Endocrine glands secrete their products immediately into the blood or interstitial fluid, without storage of the chemical. Hormones act as "messengers," and are carried by the bloodstream to different cells in the body, which interpret these messages and act on them. Typical endocrine glands are pituitary, thyroid, and adrenal glands, but not exocrine glands such as salivary glands, sweat glands and glands within the gastrointestinal tract 1. Pineal gland 2. Pituitary gland 3. Thyroid gland 4. Thymus 5. Adrenal Gland 6. Pancreas 7. Ovary 8. Testis
  • 25. THE DIGESTIVE SYSTEM Normal System The human digestive system, otherwise known as the gut or gastrointestinal tract, is essentially a continuous muscular tube about 7-8 metres long in adults running from the mouth to the anus (back passage). It is designed to process food and fluids, which are consumed on a daily basis; the main processes involve ingestion, digestion, absorption and elimination.
  • 26. SKELETAL SYSTEM 1. It protects our vital organs such as the brain, the heart and the lungs. 2. It gives us the shape that we have. Without our skeleton, we would just be a blob of blood and tissue on the floor. It allows us to move. Because our muscles are attached to our bones, when our muscles move, they move the bones, and we move.
  • 27. WARD INFORMATION/ORIENTATION Date Signature of mentor Orientation to the renal department Introduce to fellow staff and mentor Location of all policies and procedure files Location of resuscitation equipment Bleep system Visiting times Drug rounds Ward rounds Patient telephone calls Meal breaks Hand washing policy Uniform policy Infection control basic policy Procedure for arranging repairs Complaints policy Initial interview Students responsibilities Discussed
  • 28. ADMISSION TO DISCHARGE - HISS Date Signature of mentor Greeting patients and significant others Introduction to facilities Introduction to appropriate staff and patients Hiss training Admissions Nursing care Devise a plan of nursing care based on assessment with the patient Set realistic goals Delivers care in accordance with Trust policies Adapt care appropriately to individual requirements Liaise with multidisciplinary team, accurately maintain records Apply correct methods when referring to and liaise with members of the MDT Evaluate care using required methods Discharge in accordance to Trust policies
  • 29. PATIENT CARE Date Sign Applies correct procedures when monitoring vital signs Accurate recordings Understands recording charts/check lists Recognises deviations from normal or unusual findings and reports these appropriately Conducts assessments sensitively Uses all appropriate recourses to complete a comprehensive assessment Accurately records information using the correct documentation Recognises physical, psychological social and environmental factors which may adversely affect health and well being of the patient Identify appropriate legislation policies and procedures in place to protect patient health Takes appropriate action to minimise risk
  • 30. INVESTIGATIONS/PROCEDURES Date Signature of mentor Clinical procedures- the student nurse will be able to observe /participate with medical staff Renal biopsy Central line insertion Permanent neck line insertion Removal of neck line Fistula formation Tenckhoff insertion and removal Theatre preparation Discuss the rational for a clean environment within theatre area Discuss the basic principals of handling and disposing of clinical waste correctly Discuss the rational preparation of each individual case Discuss the role of the assistance in theatre
  • 31. DIALYSIS Date Signature of mentor Observe the cleaning of the exit site and dressing Discuss the rational of observation of exit site Discuss the different types of peritoneal dialysis CAPD (continuous ambulatory peritoneal dialysis) APD (automated peritoneal dialysis) IPD (intermittent peritoneal dialysis) Discuss the principles of haemodialysis Discuss the different types of haemodialysis access Neck line (temporary and permanent) Fistula Graft
  • 32. DRUGS Date Signature of mentor Storage of drugs Knows where medications are stored Understands the control of dangerous drugs Renal prescriptions Discuss the dangers of potassium in renal patients Discuss gentamycin and vancomycin therapies Discuss the administration of O2 and nebs with accurate monitoring of O2 sats Discuss the administration of intravenous drugs via volumetric and syringe devices EPO therapy Discuss why we use EPO therapy Discuss the method of administration Iron therapy Discuss what blood results to look at i.e. ferritin & HRBC Discuss the risks involved giving iron therapy
  • 33. MISCELLANEOUS Date Sign Nutrition and fluid balance Discuss renal diet Discuss importance of fluid restrictions Discuss the administration of supplements i.e. drinks and total parental nutrition(renal regime) Ordering patients meals Discuss the importance of daily weight
  • 34. Student Evaluation Form Were you allocated a mentor? …………………………………………………………………………… …………………………………………………………………………… ……………………………………………………………… Were you introduced to staff upon the ward upon your 1st day or before you commence your placement …………………………………………………………………………… …………………………………………………………………………… ……………………………………………………………… Were you orientated to the ward environment upon your 1st day or before you commenced your placement …………………………………………………………………………… …………………………………………………………………………… ……………………………………………………………… Have you worked alongside your mentor through out your placement with us? …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………… Were you allocated an Associate mentor in your mentor’s absence? …………………………………………………………………………… …………………………………………………………………………… ……………………………………………………………… Have you gain the competencies you set out to achieve? …………………………………………………………………………… …………………………………………………………………………… ……………………………………………………………… If not, can you explain the reasons why? …………………………………………………………………………… …………………………………………………………………………… ……………………………………………………………… Have you enjoyed your placement with us? …………………………………………………………………………… …………………………………………………………………………… ………………………………………………………………
  • 35. Were you made welcome throughout the placement? …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………… Did you gain enough learning opportunities? …………………………………………………………………………… …………………………………………………………………………… ……………………………………………………………… What could we do to improve learning opportunities for students? …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………… Were you made aware of the Polo File, and learning zones? …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………… Is there anything else you could suggest to improve learning for students coming onto our ward environment? …………………………………………………………………………… …………………………………………………………………………… ……………………………………………………………… Were you given the Student information pack at the commencement of you placement? ………………………………………………………………………… …………………………………