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Orthopaedics & Urology

6 North Wellington Regional

Hospital

Student Welcome Guide

Updated February 2015

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Welcome to 6 North, we are pleased to have you here. This guide aims to give you some helpful information so you can enjoy your time here.

Contents General information .....................................................................3 Orientation and Preceptor support ...............................................5 Who’s who? .................................................................................6 What services does 6 North provide? ..........................................7 Common conditions on 6 North ...................................................8 Workload ................................................................................... 10 Medication Administration ......................................................... 10 Observation ............................................................................... 11 Useful Abbreviations ................................................................. 12 Patient handover and documentation ........................................ 13 What learning opportunities are available to me? ...................... 14 What if I need help, who do I talk to? ......................................... 15 Resources and reference material ............................................. 15 Tips for success ........................................................................ 16 Treasure Hunt ........................................................................... 17 Proposed Orientation Timetable…………………………………..18

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General Information Location: 6 North is located on the 6th floor of Wellington Regional Hospital. On your first day enter the hospital through the main doors into the Atrium and take the orange lifts to the 6th floor. Once you have arrived at the 6th floor exit the lifts and turn left into 6 North. Shift times: AM 0700-1530

PM 1445- 2315

Night 2245- 0715

Please ensure that you arrive before your shift starts!

Car Parks: Car parking facilities are available within the hospital grounds as well as street parking which can sometimes be difficult to find a park. The hospital parking locations are: Off the main entrance (Adelaide Road) Off Hospital Road There is a charge for day parking

Phone Numbers Ward phone number: 04 8060996 ACNM: 80996 Emergency: 777 If the phone is ringing and you are near it

please pick it up and say where you are and your name e.g “Hello, 6 North, John speaking”

Please contact the ward if you are unable to make it to work before the start of your shift

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Break Times and Cafeterias: You are allocated one 10 minute break and one 30 minute meal break in your rostered shift. Break times are allocated at the beginning of each shift by the Pod Team leader. On 6th North we have a staff room available with kitchen facilities along with free tea and coffee. There are 4 cafeteria’s available in the hospital Vibe café: situated off the main entrance corridor very near

to the WSB lifts, level C The Clinical School Café:1st floor of the Clinical School Block The Wishbone Café: in the Atrium of Wellington Regional The “Fuel Bar”: is located in the main corridor of WSB on

level C Change Rooms and Lockers: We have male and female bathroom/toilet areas and swipe card access is required. Locker facilities for nursing students on clinical placement are available. However you will need to supply your own padlock (key or combination lock) for your locker. Swipe card access and security: Access to hospital areas is via swipe card. A swipe card will be provided to you on your placement after we have collected a $20 deposit from you. You will be required to sign that you have received a swipe card, and hand it back on your last clinical day. Also please wear your student identification card at all times when on duty.

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Orientation and preceptor support Ward 6 North endeavours to provide students with a basic

orientation and a “consistent” preceptor. However due to our large numbers of part-time staff and your set hours this is not always achievable.

Tell us what your needs are: self assess yourself, come with

a list of objectives, and tell us what you are good at and what you require help with. The earlier we know what your needs are the more we can help you.

We understand that all students are at different levels of

knowledge and ability. Keep the communication lines open. At times you may feel

confused, disorientated, scared and uncomfortable. We want your clinical experience to be a positive one.

There are ongoing orthopaedic and urology tutorials for

nursing staff, nursing students are welcome to attend these sessions.

As part of your perioperative nursing placement you will gain

valuable experience working alongside different members of MDT and registered nurses.

We hope you enjoy your time here at 6 North

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Nurses Charge Nurse Manager : Tracey Kasner

Associate Charge Nurse Managers: Wendy Costa

Clinical Nurse Specialist Urology: Robert Hale

Nurse Educators: Leanne Grout & Emma Lange

Orthopaedic Consultants Mr Peter Devane Mr Tim Greg Mr Chris Hoffman Mr Grant Kiddle Mr Fred Phillips Mr Robert Rowan Mr Mark Sherwood Mr Willis Mr Gareth Coulter Mr Ilia Elkinson

Urology Consultants Mr Andrew Kennedy-Smith Mr Richard Robinson Mr Grant Russell Mr Rodney Studd

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What services does 6 North Provide? Orthopaedics

Joint replacements (including hip and knee) Preventative surgery (Scoliosis) Osteotomy (the repair of a bent or crooked bone to improve

alignment) Soft tissue repair (such as reconstruction of tendons,

ligaments and wound treatment) Bunions/Hallux valgus (Bunion Treatment) Trauma management from varied injuries such as limbs, hips

and spines Urology in-patients Acute admissions Haematuria Renal Colic Urosepsis Obstructive uropathy Inflammatory problems Trauma and self induced injury

Elective surgery Endoscopic Laparoscopic Percutaneous Open

Urology out-patients Consultant clinics Diagnostic clinics: Prostate biopsy Flexible cystoscopy Urodynamics Uroflow

Nurse led clinics TURP follow up Radical Prostatectomy follow up Continence BCG immunotherapy Intravesical cytotoxic’s

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Common Conditions on 6 North Hip Surgery There are several types of hip surgery and are broken down into Elective Surgery and Acute Surgery from slips, falls or other trauma. The aim is too Reduce pain, improve motion and minimise wear and tear. Total Hip joint replacement is when the damaged part of the hip is removed by making an incision along side the hip joint and is then replaced by a new prosthetic joint. The prosthetic joint consists of a ball and stem (femoral component) and a socket (acetabular component) which can be held in place by using special acrylic bone cement or by allowing the bone to grow around the new joint. The prosthetic joints can be made out of metals (e.g stainless steel, chrome, titanium) ceramics, plastic or a combination of these materials. Hemi arthroplasty is when only half of the hip joint is replaced. It depends on which part of the joint is damaged usually by osteoarthritis. The affected part is removed (head and neck of femur or the acetabular socket) and replaced with the appropriate prosthesis. Neck of Femur fractures are common in our elderly generation of people, often resulting from a fall. Most are fixed by surgery which can be done in various ways depending on the type of fracture sustained. Knee Surgery is considered a major operation and involves the removal of the knee cap, the rough or irregular bone on either or both the femur and the tibia so that the artificial knee components can be replaced allowing the knee to move smoothly. It also requires the loosening and re-tightening of some muscles and ligaments. There are 3 artificial components to the knee joint which are held in place by using specialised bone cement. These components are the femoral component (to replace he end of the femur), the tibial component (to replace the end of the tibia) and the patella component which replaces the back of the knee cap.

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Continuous Bladder Irrigation (CBI) involves inserting a 3-way catheter to irrigate the bladder by continuous flow of water into and out of the bladder to discourage a clot formation, assist in the removal of clots and prevent the catheter blocking up because of blood clots. The main indications for the use of CBI is post operatively following a trans-urethral resection of the prostate, or in patients presenting with haematuria, resulting in clot formation/ clot retention. CBI is very dangerous as There is potential for the bladder to rupture, due to

too much fluid going in and not able to come out. Hypovolaemic shock due to heavy haematuria Sepsis- due to instrumentation of the urinary tract

or even catheterisation itself Rarely, Trans-Urethral syndrome due to the

absorption of the irrigating flood which enters the blood stream. The patient may become confused, disorientated, convulse or become comatosed. They may also have fluid overload symptoms such as pulmonary oedema.

Patients having CBI require close observation

and need accurate fluid balance charts!

Urosepsis is an extreme form of an infection in the urinary tract and/or the male genital tract (e.g. prostate) in which bacteria has entered the blood stream. This causes the patient to have a systemic inflammatory response with symptoms of fever and/or chills, tachycardia, tachypnea, respiratory alkalosis, flank pain, renal angle tenderness, ureteric or renal colic, dysuria may be present. Treatment of Urosepsis involves close monitoring, management of fever, IV fluid to help with blood pressure and hydration, pain relief and antibiotic therapy which are to be started immediately after urine samples and blood samples have been obtained.

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Workload…..

Year 1: You will be working under direct direction during your clinical experience

Year 2: You will be supervised until you and your buddy decide what nursing practice you are safe and competent to perform

Year 3: You will begin taking a patient load when your buddy has assessed your ability and competence. If you do not feel safe with your allocated patient load (i.e. too many, or too complex patients) SAY SO!!

You will be expected to carry out all the cares for your patients. For those cares that you have not covered or able to do, you should negotiate a time with your buddy for him/her to carry them out for you/with you.

The cares you will carry out include medications, observations, checking and dressing surgical wounds as required, assisting with ADL’s, mobilisation and writing patient’s nursing notes.

All these cares will be explained and demonstrated to you before you are expected to carry them out. Give constant feedback and ask for feedback from your buddy and seek help whenever you need it.

Medication Administration All students on clinical experience must give medication under direct supervision/direction of a registered nurse. Students can not be the second person for checking IV fluids or controlled drugs. The checking process involves all the 5 rights. For any drug check: Right route (IV,IM,SC, SL, INH) Right time and frequency of medication

(QID, TDS, BD, PRN) Right dose (g, mg,mcg, units, ml) Right drug (check careful for brand and

generic names of drug) Right client (check wristband, ask full

name and date of birth

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Medication Administration continued…. The process is not complete until you have signed the drug chart correctly and your registered nurse buddy has countersigned. Refer to your BACHELOR OF NURSING PRACTICUM HANDBOOK-medication guidelines. Check out C&C DHB policy ‘Intravenous medicine and fluid administration- student nurses and student midwives’ IVC-03 Controlled Drugs are drugs which have high potential for risk or drug abuse. The use of these drugs and distribution is tightly controlled. Examples of these drugs are: Benzodiazepines, Morphine, Pethidine, Fentanyl, Methadone. PYXIS MACHINE is a drug dispensing machine that needs a user ID and fingerprint or password to access the machine. It is a touch screen machine that shows the name of the patients in the ward and provides a list of medications. This machine can track who logs in to take out medications, dose of meds taken, and the time they where taken from the machine. Observations Blood Pressure (BP) Use the sphygmomanometer and stethoscope until you are

competent, and then you can use the Dynamap. Report any abnormally high or low reading to

your buddy. Consider the patients normal baseline and current medication.

Note that the BP recording in some instances may mean withholding certain drugs e.g. Captoprill. Discuss this with your buddy.

Pulse Take radial pulse reading. Take pulse for 60 seconds. Report anything abnormal e.g. slow, fast, irregular

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Observations continued… Temperature Use the tympanic thermometer for routine

temp taking. Report any temperature above 37.5 degrees

and temperatures below 35.8 Respirations Monitor all patients on narcotic analgesia e.g. PCA, or

Epidural Short of breath, observe rate and depth Post op patients

O2 sats Monitor all patients, and on narcotic analgesia Immediate post op patients At risk of DVT or PE Patients receiving oxygen therapy

Neurovascular Obs Colour (pink, pale, dusty) Warmth (warm, cool, hot ) Movement (Nil, moving fingers and toes) Sensation ( Nil, tingling, pins & needles, dull) Capillary refill

Check out C&C DHB policy “Clinical observations and monitoring of patients in medical and surgical nursing CPP AST-01

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Useful abbreviations You may find the below abbreviations written on the patient handover sheet and some may not be accepted abbreviations. The handover sheet is not a legal document and is shredded at the end of each shift. # Fracture Addit Add on/extra

TKJR Total knee joint replacement Mane’ Morning

THJR Total hip joint replacement Nocte’ Night

TSJR Total shoulder joint replacement Obs Observations

ORIF Open reduction, internal fixation D/C Discharge

NOF Neck of femur O2sat Oxygen saturation

RCSP Richards compressed screw and plate NWB Non weight bearing

NOH Neck of humerus TWB Touch weight bearing

CWMS Colour, warmth, movement sensation PWB Partial weight bearing

AK Above knee ABs Antibiotics

BK Below knee KCL Potassium chloride

NFR Not for resus GA General anaesthetic

R/O Removal of IDC Indwelling catheter

N/Saline Normal saline IM Intramuscular

D/Saline Dextrose saline DVT Deep vein thrombosis

H’ cell Haemacell PE Pulmonary embolisim

H’vac Haemovac ADL’s Activity of daily living

PCA Patient controlled analgesia MUA Manipulation under anaesthetic

Epid Epidural Dsg Dressing

Disloc Dislocated HNPU Has not passed urine

Reloc Relocated HPU Has passed urine

Patient handover and documentation At the beginning of your shift you will

take part in patient handover at the bedside of each patient, a Registered nurse will give you (and the other nurses) verbal information about each patient and what has happened for them during their shift.

At the end of your shift you will be expected to present your patients to the staff that are coming on while doing the walk around handover with the guidance of your buddy.

You will also be expected to document in patients notes, such as progress notes, update ADP, complete care plan and document assessments. Before you write in patients notes a rough copy must be drafted for your buddy to critique making sure that you have all the information and haven’t left anything out.

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There are legal and ethical issues when writing in patients notes Be objective- not subjective

Further information on patient handover and documentation requirements can be found by reading C&C DHB policy ‘Nursing/midwifery handover’ NUR-16 or Article- Campos. N. (2009) The legalities of nursing

documentation. Nursing Management, 40(8)16-19 What learning opportunities are there available to me? There are plenty of learning opportunities here on 6 North they range from going to theatre, reading our supply of resources to getting the chance to practice every day nursing skills. By being pro active about your learning we are sure that you will enjoy your time here. Some of the learning opportunities are listed below. Orthopaedic Visit theatre to watch and operation and spend time at PACU

(post anaesthetic care unit) Occupational therapy Physiotherapy

Urology Visit theatre to watch an operation Spend time with CNS urology Visit urodynamics Visit the urological clinics and outpatient screening

Nursing skills Observations- BP, pulse, temp, resp rates, o2 saturations &

LOC Pain assessment (numerical & visual analogue scale)

P.Q.R.S.T monitoring and evaluation Management of hypoglycaemia in a conscious and

unconscious patient Monitoring & dressing surgical wounds including basic

dressing and pin site cares. Suture and clip removal. Wound drain removal IDC insertion and care, CBI and nephrostomy care Patient ADL’s Patient mobility

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Precautions relating to joint replacements Neurovascular observations and signs of compartment

syndrome Charting: fluid balance, drug charts, food charts, BSL, spinal

observation Medication administration under supervision IV fluid and antibiotic reconstruction Patient case management Time management (especially 3rd year students) Team nursing Manual handling skills and equipment Falls assessment and prevention Pressure area assessment and prevention What if I need help, who do I talk to? At 6 North we are here to help support you and your learning. It is important to have effective communication so you can enjoy your placement here and make the most of your learning opportunities. However if you do want to talk to someone or require extra help these people can assist: Your preceptor/ buddy that you are working with Your university lecturer Leanne Grout or Emma Lange- Nurse educators Wendy Costa- ACNM Nik Florance- ACNM Tracey Kasner- CNM

Don’t be afraid to ask- We don’t bite

Resources and reference material. Blue and yellow folders in the pods. Blue contains orthopaedic information and yellow contains urology information. Both folders have information on types of procedures, relevant articles and post op plan for to follow when caring for your patient. Policies Delegation and supervision of patient care related activities

NUR-10 Enrolled nurses and Nurse assistants- roles and

responsibilities NUR 11a Pin site cares INT-16

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Urinary catheter-bladder washout via urethral/supra-pubic or 3 way irrigation catheters (adults) INT-20

Book: Orthopaedic general hints for nursing and medical

staff, located in Nurse resource room, pod B or Nurse Educators office

There are plenty of other resources available for you to use located in the Nurse Resource room

Tips for Success Don’ts Perform tasks which you are not competent to

do If you are sick, please let us know, don’t just not show up Don’t be late, be punctual. Remember that you are training to

be a health professional and you need to display professional and accountable behaviour

Don’t suffer in silence, if you have a personal or professional problem tell someone. We can help and are happy to do so

Do’s Ask questions, there is no such thing as a silly question, just

be mindful of where you are asking the question Wear a clean ironed uniform each day. Hair must be tied

back and no cardigans are to be worn on the floor Be self-directed in your time here, if you don’t seek out

opportunities then you may not get the placement you want Be respectful to permanent staff, patients, and

families/whanau Learn the basics first- learn to walk before you run We are open to feedback so please tell us your thoughts and

opinions Please always use the nursing process in everything that you

do DO know the emergency procedure and numbers

“Resuscitation and medical emergencies” EME-04 The number for a cardiac arrest or medical emergency is 777 Enjoy your time here

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ERAS Pathway Enhanced Recovery After Surgery is a patient centred method of optimising surgical outcomes. This is done by improving patient experience and improving clinical outcomes. Primary care

Manage anaemia

Manage hypertension

Manage pre-existing comorbidities

Provide health living advice

Improve fitness

Adequate nutritional status Pre operative assessment

Pre-anaesthetic clinic

Patient education class

Given discharge date and discharge planning

Patient information booklet Peri-operative care

Multimodal opiate sparing anaesthetic and analgesia

Minimise post-op nausea and vomiting

Goal directed IV therapy Post op care

Early nutrition

IV fluids removed within 12 hours

Standardised careplan documentation

Early mobilisation

Appropriate effective analgesia Discharge and follow-up care

Planned discharge on day 3-4 when criteria met

Telephone follow-up from ward 48hrs after discharge

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The Active Cycle of Breathing

1. BREATHING CONTROL

Relax you shoulders

Relax your chest

Breathe as you normall would for 20-30 seconds 2. DEEP BREATHS

Breathe in deeply through your nose

Hold 2 seconds

Breathe out through your mouth Repeat 3-4x

3. HUFFING

Take a medium sized breath in through an open mouth

Breathe out forcefully through an open mouth (as if you are fogging up a mirror)

4. COUGHING

To move any secretions in your chest cough 1-2x

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Treasure Hunt Your task is to locate all of these items which are on 6 North

Write down where you have found them.

List the equipment found in the equipment room .........................................

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Fire hydrant and extinguisher.......................................................................

Normal saline 1000ml bag ...........................................................................

Plasmalyte 1000ml bag ................................................................................

10 and 20 ml syringe ....................................................................................

Dressing trolley ............................................................................................

Blueey sheets ..............................................................................................

Incontinence pads ........................................................................................

Hudson and re-breather mask .....................................................................

Nasal prongs ................................................................................................

White tape ....................................................................................................

Dressing pack ..............................................................................................

Staffroom/ kitchen ........................................................................................

Staff toilets ...................................................................................................

Resus Trolley ...............................................................................................

Ted stockings ...............................................................................................

Emesis bowls ...............................................................................................

Sterile gloves ...............................................................................................

Gauze ..........................................................................................................

Patient’s locker key .....................................................................................

Thermometers ..............................................................................................

BP equipment ..............................................................................................

Zimmer frames .............................................................................................

Oxygen tubing ..............................................................................................

Towels and linen ..........................................................................................

Alcohol swabs ..............................................................................................

Urine measurement jug ................................................................................

Bed pans und urine bottles .........................................................................

BSL machine................................................................................................

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Student nurse Orientation Proposed - Day One if able

0800 Welcome –Nurse Educator Swipe Cards Roster Expectations

6 North

0800 Tour of the ward-Nurse Educator

6 North

0830 Post operative Complications EWS Medication chart

1015 Morning tea

1030 Treasure Hunt

1130 Self directed learning. Base self in a pod and look at ADP’s, clinical notes, Blue and yellow folders, Braden chart, Falls chart, PAR/EWS charts, Pain assessment, ERAS patient education books.